An examination of issues resulting from a global shift away from smoking toward ecigarette use: the global impact of declining cigarette sales and non-smokers becoming vapers
Note on perspective
1. The benefits and drawbacks of the shift to vaping for society
- Public health impact
- Economic impact
- Environmental impact, planetary impact
2. The benefits and drawbacks for the individual
- Health impact for the individual
- Economic benefits for the individual
- Social benefits for the individual
3. Issues surrounding non-smokers initiating nicotine use via ecigs
- The Swedish experience
- The real impact of nicotine consumption
- The questions
- Impossibility of predicting scale
- When new technology eliminates the old: the timescales
This material describes a UK / EU viewpoint. It may be transferable, but caution needs to be applied, especially with regard to application of any specifics to the USA: the money supply for anti-THR activities there is enormous by UK standards and probably twenty times the scale. As a direct result, the pressures are different and above all, the actors are different. As examples of this:
Money is everything in the legislative and regulatory area of tobacco and smoking cessation, and it is more accurate to think of this area as a subset of fiscal policy rather than health policy.
In the USA, for instance, only a tiny fraction of the individual States' billions in MSA funding is assigned to smoking-related health initiatives, and the bulk of the money is assigned to the general fund. One State uses it to fund staff pensions. Therefore the security and maintenance of supply of these funds is a crucial issue for States and can even affect their solvency. The MSA fee payments to each State are directly related to the amount of cigarettes sold; there are some buffers and inflation hedges but essentially the MSA fees relate to the stick volume. This is a conflict of interest of indescribable proportions since States are in effect forced to protect smoking, and some clearly do everything in their power to remove any threat to the revenues.
Serious COIs are everywhere in the revenue distribution channels that connect government with cigarette sales and the pharmaceutical and Public Health industries; they can be considered as normal and universal. Strong financial pressures combined with greed and incompetence ensure that smoking-related revenues are robustly protected.
Money is also the principal driver in the Public Health industry and it is crucial to remember this: it defines all action, policy and affiliation. 'Public health' organisations not directly connected to street-level interventions by statutory order tend to be lobbying groups with an agenda dictated by their funders. The health of the public is quite low on the list of priorities for many of them.
The difference in the money supply and its origins in the USA, EU and UK clearly results in differences between the respective approaches, players, public perspective and regulatory outcomes.
There are three ways to measure advantage or disadvantage to society from the shift to EV use (electronic vapourisers) and away from smoking: public health, economic impact, and planetary impact.
General THR issues
THR or tobacco harm reduction refers to substitution of cigarette smoking with alternative, smokefree products. Consumers should be given the choice of which products they wish to use, since that is an inalienable right assuming that they pay for any personal or societal costs. If government wishes to manage or influence that choice, this should be subject to a public debate unrestricted in any way since it significantly affects personal health. Modern technology gives us many more choices: for example clean nicotine products, purified smokeless tobacco products, clean nicotine delivery systems such as EVs, and reduced-smoke HnB systems. Some of these modern products appear to have an absolute risk elevation too low to worry about, and compared to smoking they are multiple orders of magnitude safer. Government policy is the only thing stopping consumers moving en masse to far safer products, and therefore we can legitimately question whether this is about health or money.
The most intensively studied product, Swedish Snus (the local, specially-processed oral tobacco popular in Sweden) has a health impact in the modern era too small to be reliably measured with regard to specific health risks . Since about 20% of the adult population are Snusers and about 10% are smokers and there are decades of facts and data on this phenomenon, which has resulted in unique national health figures for Sweden, the basic facts of THR are no longer in dispute: unrestricted access to safer products results in huge public health gains.
The biggest problem with smoking is that it provides enormous funds for government; this is not compatible with free choice for the individual, since in effect tobacco is a government business - they make far more from it than anyone else. To illustrate the problem, in the UK 18 out of 20 cigarettes are bought directly from the government, and the frontend revenues (typically £12bn/year) are almost certainly equalled by the backend savings, and then added to by other channels such as corporation taxes and income tax; the concept that such enormous wealth can be willingly relinquished is simply not logical. Threats to the revenue channels are resisted by direct legislation, or by delegation of the legislation to a senior authority (here, the EU), and by mobilising the recipients of some of the funds generated to lobby for removal of the threat by the use of spurious objections and propaganda.
So, these are the fundamental issues surrounding vaping or any other really effective approach to the reduction of smoking prevalence. It is clear that:
The only 'danger' is to cigarette sales, drug sales for treating smoking-related disease, and government funds - but the propaganda assault is designed to camouflage this. A country that allows full, unhindered, unrestricted access to THR products has a steadily reducing smoking prevalence, disappearing smoking-related morbidity and disappearing smoking-related mortality. And, unfortunately, an inexorably-reducing pile of money generated by smoking, disease and early death - which is the main problem. Only Sweden has ever had the courage to put public health above greed.
Thus, any benefit to society or the individual has to first face almost insurmountable odds.
We know from Sweden's unique national health statistics (the facts) and their vast data resources (the evidence for the mechanisms that result in facts) that lifetime Snus consumption has an average expectation of lifespan reduction of 6 weeks. This compares with about 8 years for all smokers on average, and about a 23-year lifespan reduction for those dying of smoking related disease before age 55 on average. The negative health impact of Snus is too small to be statistically identifiable with any reliability. In the modern era, Snus has no association with cancer of any kind, or CVD of any kind. For example it has no association with oral cancer, and indeed Sweden has the lowest male oral cancer rate in Europe (Snus is mostly consumed by men); it has no association with pancreatic cancer (an earlier apparent risk elevation was disproved); it has no elevation of risk for stroke, but there does appear to be a small increase in risk for non-survivable episodes. All the numbers involved are so small that identification of any risk is difficult at best; it has been demonstrated that lifetime consumption of this type of modern, ultra low risk product has less health impact than 3 months of smoking.
The only way that any issues at all can be identified is due to the enormous size of the data resource - it dwarfs the resources available for NRTs.
The 'modern era'
When discussing these issues it is important to use facts and data from modern, Western low-risk products, since that is what the issues revolve around. We are not concerned with historic smokeless tobacco products such as the old US 'chew', since modern products such as Snus are not comparable in any way: they comply with the Gothiatek manufacturing standard and most carcinogens are removed by modern processing methods.
South Asian oral tobacco-containing products such as gutka and paan are another irrelevancy in the Western debate. They have known risk elevations that have no relevance whatsoever to Snus consumption, for example, and attempts to conflate the two are probably best regarded as fraudulent. There is a concerted effort by cigarette market protectionists to conflate use of South Asian ST products and historic Western products with use of modern ultra low risk THR products, and this must be guarded against. For example:
Snus vs ecigs
An important question is whether or not other modern products will achieve the same safety profile as Snus. Due to its hundred-year plus history in Sweden, we know the health impact precisely. We don't have even a fraction of this data resource for NRTs, which have been available since 1984, never mind any of the modern THR products such as dissolvables and EVs. (Dissolvables are the oral dissolving tobacco and nicotine products; 'EV' or electric/electronic vaporiser is a more accurate term for an 'ecig'.)
Some think EVs will be as safe as Snus, some think safer (somehow), some think not. There is some potential for lung issues with EVs, especially with regard to the flavourings. It is difficult to see how anything more serious than stage 1 COPD in a small number of cases could result, given the seemingly innocuous profile of the vapour, but until we have long-term data it is impossible to say. There is certainly a clear risk for aggravation of pre-existing serious lung disease caused by smoking, but that is another matter. For example, emphysema patients are at risk of contracting pneumonia, and it is possible that some types of EV refill might pose an issue here.
In general, EVs appear to have a safety profile similar to Snus, although this is simply speculation until we have the long-term data. The signs are certainly good though: with 10 years' use, over 25 million users globally, and therefore approaching 100 million user-years at 2015, no disease paths specific to EVs can be demonstrated.
It is generally recognised that THR is the most efficient way to allow smokers to quit, once education and other measures have reduced smoking prevalence to around 20% of the adult population from a figure originally more than double this. In fact no other method has ever worked (see the 20% Prevalence Rule).
In one or two countries it has been suggested that very high tobacco tax revenues have pushed the prevalence rate significantly below 20%, but when this claim is examined we find that (a) the smoking prevalence rate has been measured in a different way in order to achieve a lower figure (by use of the 'daily smoker' rate instead of the 'past 30 day' rate, for example), and/or by ignoring the large black market in cigarettes and loose tobacco created by high prices. Such claims can be disregarded as they appear to have the hallmarks of disinformation.
The health impact from modern THR products is difficult to measure as risk elevation is so low in absolute terms. There is no comparison at all with smoking. Even the most conservative medical professionals expert in THR issues say that vaping has at the most 5% of the risk of smoking and therefore a risk reduction of 20 times; this is a worst-case scenario and most likely by a very long way indeed, in order to ensure such professionals cannot be caught out later. Entire panels of the most senior tobacco control professionals in the world have stated this view repeatedly at conferences. If people such as Derek Yach (who developed the FCTC), John Britton (the RCP's principal spokesperson on tobacco) and JF Etter (continental Europe's most senior tobacco control professional) are telling us vaping has a fraction of the risk of smoking, then any contrary opinion held by enormously wealthy propagandists with a tiny fraction of the medical expertise is not really worth serious consideration - especially when their funding and continued employment is directly linked to cigarette tax revenues, MSA funds and drug sales.
Smokers have the right to manage their own health and reduce risk, so they should be allowed to buy safer products. If society makes the decision to reduce smoking prevalence, then free access to THR products is the ethically and morally correct route to doing so, rather than coercion. Indeed, free access to THR solutions is much more efficient and effective than coercion, as can be clearly seen from the Swedish experience. It is also cost-free; but we must note that a solution to society's costs from smoking may be cost-free to the state in terms of outlay, but financially crippling in terms of the loss of very substantial revenues and savings. After all, this is why no one really wants to solve the smoking problem - it is all just meaningless bluster and hot air. Smoking generates too much money for too many people, including those who make the laws, for there to be any realistic prospect of getting rid of it.
If smoking prevalence has been reduced to around 20% from above 40%, then it appears extremely unlikely that any approach other than unrestricted access to THR will then have any significant effect at all, since no country is an exception to the 20% Prevalence Rule where it applies. This the principal reason THR is unwelcome anywhere except Sweden.
Why people smoke
There must be dozens of reasons for this. One significant reason is self-medication, and there are multiple divisions of this aspect alone. We now know that nicotine is a normal part of the diet (it is contained in many vegetables); it is an active component in the diet since it has multiple functions, much like its sister and co-located compound nicotinic acid (vitamin B3); everyone consumes it; everyone tests positive for it (the measurable nicotine blood plasma background level in persons with a good diet is 2 or 3ng/ml); and it is very likely that - as is normal for all nutrients - some people need to supplement it, depending on genetic make-up.
Nicotine prevents and treats several neurodegenerative, auto-immune and inflammatory diseases, and assists in some forms of cognitive dysfunction. It is an essentially harmless, normal dietary ingredient that is almost certainly a nutrient that will eventually be given a B vitamin classification once the smoking/nicotine taboo has expired. If people wish to supplement their diet then they should be allowed to do so by the use of consumer products, there is no need to pay for licensed medicines for this purpose.
Modern low-risk products
There is no longer any need to smoke tobacco in order to gain the benefits. Modern products have too low a health impact to worry about - long-term coffee consumption of significant volume is likely to have a greater health impact. All other lifestyle decisions will certainly have a far greater effect on health - diet and exercise choices, and sedentary versus active lifestyles, will have a much greater effect on health than THR products in the modern era.
THR for smokers
Smokers will benefit by switching to a modern ultra low risk THR product. In Sweden, we can see that smokers who switch to Snus and smokers who totally quit all tobacco and nicotine use have the same health outcomes. All become non-smokers in terms of health outcomes. Any difference in outcomes is too small to be clinically significant.
Taking up smoking
If a person takes up smoking then at some point it usually becomes difficult to quit. Smoking, unlike pure nicotine consumption*, causes dependence. This dependence can legitimately be called addiction due to the significant risk of harm. It would be better if people started to vape rather than smoke, since at this point in time no identifiable health consequences attributable to vaping can be seen.
* NB: it is impossible to clinically demonstrate any potential for dependence for nicotine. Multiple clinical trials for investigation of treatments for assorted diseases have shown that no matter how much nicotine was administered daily to never-smokers for up to 6 months, no subject ever displayed the smallest sign of dependence. (See References pages here.)
Taking up vaping
Because it is impossible for the death and disease burden from vaping compared to smoking to be any less than a 100-fold reduction, public health will see the largest boost since the discovery of antibiotics. Some think vaping will prove at least 1,000 times safer than smoking. It is also perfectly reasonable to state that an individual consumer with a mind to maximising risk reduction, at the cost of reducing some consumer benefits, can easily ensure their chosen vaping solution has something of the order of 10,000 times less risk than smoking; low-power unflavoured-refill vaping presents hardly any identifiable risk of any scale.
For society as a whole, if people who would have smoked instead take up vaping, and never transition to smoking, then this is a huge public health benefit.
This applies especially to youth because smokers tend to start young, and since more than one in five youths are reported to be smokers then removing that initial start as a smoker would qualify as a huge benefit to health overall. If young people start vaping instead of smoking, there are clearly massive benefits to public health, as long as there is no gateway effect.
The question then becomes, is there is a gateway from vaping to smoking - and if this existed, then would it create more smokers than already existed; in other words would even more youth (and adults) smoke than do already. From the exceptionally honest and current UK statistics obtained by YouGov and administered by Prof West, we see that - in the UK - there is no gateway effect. The only gateway is out of smoking.
Obviously we can see from Sweden that THR eventually eliminates smoking and smoking-related disease, or at least a locally-acceptable smokeless tobacco product does. Male smoking prevalence will have fallen to only 5% by around 2016. Therefore, no hypothetical objections have any value - if there is no smoking, then, rather obviously, there is no smoking. If there is no smoking, and tobacco-related disease stats fall through the floor, then QED no objections have any validity.
(There is one partly-valid objection: if tobacco or nicotine use is proscribed due to zealotry in some form - religion or some form of warped ideology perhaps - then indeed there might be an objection to people consuming products not available in a simple rural lifestyle extant a thousand years ago; so presumably coffee, tea, chocolate, sugar, wine, whisky, beer or anything other than plants, roots and berries would be off-limits as well. This point of view does not seem reasonable in the modern era. Zealots of any/all types are perfectly free to go off and create their own communities with their own rules, and many have done so; it seems best if they leave the rest of us alone. The practical problem with this approach is that such action does not convey the enormous salaries that well-funded zealotry attracts in modern society. Thus, in practice, it appears that most zealots prefer giant salaries, respected positions within the power structure and a comfortable lifestyle to living in communities that actually accord with their ideals.)
As far as vaping is concerned, the only hard data is from the UK, where (at 2014) youth smoking is at an all-time low, no statistically-measurable number of youths (under-18s) who are regular vapers can be found, 33% of vapers have quit smoking, 18% of smokers have switched to vaping, and as this figure has tripled in two years it means that soon 25% of smokers will have switched; as vaping grows, smoking will decline. So, as far as the UK is concerned, the answer is clear: vaping is killing off smoking. Whatever way the figures are interpreted, it's all good: if smoking continues to decline significantly, then even if new and apparently negative factors appear temporarily, they cannot ultimately be of any importance because with very low levels of smoking there are obviously no negatives. This point is obvious from the switch to Snus and away from smoking that has occurred in Sweden. As far as the health issue is concerned, the elimination of smoking means that there cannot be any negatives. Unless there is no health benefit from the substitution, of course; but in Sweden it is clear that there has been an unprecedented boost to public health, with rather obvious metrics available such as the lowest rate of tobacco-related mortality of any developed country by a wide margin, and the lowest rate of male lung cancer and oral cancer in the EU. You can't really argue with that.
However the UK stats for 2013/14 are the first to really show this effect, so we are at the start of the curve and there is no proof it will stay that way. Logic dictates that things will continue as they are, since the effects can be seen to be growing, but this is not proof. The regulatory climate is also important, since this is designed to slow down the replacement of smoking by vaping in order to protect the status quo (the cigarette market is the foundation of the world's largest gravy train, worth more than $1 trillion a year, which we call 'the smoking economy'; it is an immensely powerful machine that is well-protected).
The US statistics can be ignored, as it is clear the CDC are so corrupt that both the validity of the US smoking-related stats and certainly their presentation and interpretation are not only suspect but more than likely fraudulent . Luckily we have access to those from other countries, and where these all paint a very different picture to that presented by the CDC - such as those from the UK and France, which in contrast are honestly and efficiently obtained and presented rapidly in full - we can choose which to believe.
Non-smokers becoming vapers
If people who would not have smoked take up vaping (including youth), then there is very little negative effect for public health that can be seen at this time; the balance of advantage versus disadvantage is strongly positive.
One factor here is dependence on nicotine created by vaping, but this is undemonstrated despite how easily it could be shown in clinical trials if it were possible. Dependence on nicotine created by smoking but then continued without smoke has much the same health or social impact as dependence on coffee, although it has been suggested that coffee may the worst of the two as regards health .
No clinical significance can be demonstrated for nicotine consumption - on average it has no measurable impact on health (outside of smoking, of course). We already know that consumption of supra-dietary nicotine at population level without smoke has no clinical significance, so that no significant harm appears likely from a new way of consuming nicotine. It is also becoming clearer that since nicotine is an active ingredient in the normal diet, and a closely-related compound is a vitamin (nicotinic acid is vitamin B3), and it has measurable beneficial effects on some medical conditions , and it has a measurable preventative effect for some of these conditions, then (a) nicotine in the diet is beneficial, and (b) once it is widely accepted as beneficial then it may be allocated a B vitamin number, at some point in the future as the taboo gradually becomes less powerful.
Currently nicotine is viewed in the same way as smoking, but this is an erroneous conflation; it has no relation to fact and is a fabricated construct. Nicotine supplementation is likely to be a good thing for a proportion of the population.
Can vaping cause disease?
This seems unlikely at large scale, but we know that it is inevitable in very low numbers since any/all activities have some negative effects. We may see a non-statistically measurable number of cases of COPD, for example.
Sub-ohming 20ml of buttercream-flavoured refill liquid daily is a different matter, and abuse is just as likely to result in negative health impact as it is for any other consumption type.
It seems highly unlikely that vaping will create statistically-identifiable numbers of persons who become dependendent on nicotine supplementation, as this is impossible to demonstrate in clinical trials with other forms of nicotine delivery with never-smokers. However it may be possible that an ultra-efficient delivery system may create a small and statistically-invisible number of cases of dependence, especially if high-power devices can also by accident or design deliver nicotine potentiators such as high levels of aldehydes and additional tobacco alkaloids. It seems extremely unlikely that clinically-significant numbers of dependent cases could be created unless this was the design objective. (Anything can be made to cause dependence if any amount of any ingredient is allowed.)
We should also examine the benefit side.
So for the population level health area - public health - vaping by never-smokers almost certainly has a neutral impact no matter the pathway into vaping and at whatever age. However this does not cover all societal pros and cons, there is also an economic issue and an over-population issue (a global / planetary issue if preferred).
ETS (environmental tobacco smoke or 2nd-hand smoke) may have a public health impact, but 2nd-hand vapour will never be shown as harmful to health. This is because there are no toxic levels of ingredients that can be found in exhaled vapour - there is no 'sidestream' vapour as with cigarettes, any vapour present has been exhaled. There are certainly materials to be found that would be toxic in high doses, but trace levels of most contaminants (some would say all) cannot be said to be harmful.
When examining an analysis of vapour, the first question that must be asked is: is this vapour exhaled? The ingredient profile of mainstream vapour and exhaled vapour is different, as it has been filtered. There is no agreed lab protocol for machine filtering of vapour, therefore it must be exhaled by human subjects in a sealed chamber. The second question is: was the chamber also tested with the subjects using a dummy device to simulate the inhalation/exhalation cycle but with no chemical load? This is vital since people normally exhale materials such as formaldehyde, for example, and the levels may change according to the inhalation vacuum and not be related to any chemical inhaled; so a subtraction procedure is necessary. Tests run by independent researchers have failed to locate any exhaled materials of potential toxicity in any significant amount, and the general levels of such materials, where present, are about 1,000 times lower than present in tobacco smoke.
Vapour only persists in the atmosphere for a short time as it is a water-based aerosol. Unlike tobacco smoke, it disappears without trace, fairly quickly. Therefore any impact is reduced to those present at the time of exhalation. In general it would need direct inhalation of exhaled vapour by mouth-to-mouth contact before any measurable absorption could take place.
The 2nd-hand nicotine issue
Before any measure of nicotine in the atmosphere or absorbed by bystanders is discussed, it is important to recognise that nicotine is present in the diet and measurable in everyone. All large-scale clinical trials report that everyone tests positive for nicotine, without exception - even in a clinical trial with 800 subjects, every subject tested positive. In the healthy individual with a proper diet, at least, nicotine and/or its metabolytes can easily be measured.
In the past, it was said that a background level of up to 3ng/ml plasma nicotine level could be measured in the normal non-smoker with a healthy diet (source: Benowitz), since nicotine is present in many vegetables, and in other foodstuffs such as tea. Presumably this level will decrease as diets become worse, with fewer people eating fresh vegetables or in lower volume. Note that test kits for identifying smokers that use nicotine, cotinine or 3-Hcot (metabolytes) as the identifier always need to have a substantial and non-zero minimum start point for a positive result, since everyone tests positive for nicotine from dietary sources; this is why an exhaled carbon monoxide test machine is the only reliable way to test for smoking status.
It is extremely unlikely that inhalation of environmental vapour could ever produce nicotine levels in subjects that approach the levels present in a person with a healthy diet. Even if it could, it certainly cannot not be regarded as a health hazard or some kind of negative; otherwise people would be warned against eating tomatoes and potatoes. Indeed, there is more likely to be a problem with unhealthy diets reducing the availability of active, beneficial ingredients; dietary nicotine supplementation is likely to be beneficial for a significant proportion of the population. We already know from the amounts needed for vitamin B3 supplementation (up to 2,000mg per day) that supplementation of dietary nicotine compounds to show observable benefit, in this case for cognitive function improvements, is not limited to small-scale additions: substantial amounts may be needed. Perhaps this is why smokers are protected from some medical conditions when measured at or before middle age: they receive a significant nutritional boost. However, smokers eventually become too ill on average to show such benefits, so this effect must be measured before smoking takes its toll. Nicotine consumption and smoking are not the same and should never be treated as the same; in fact treating smoking and nicotine consumption as the same or similar is the classic sign of a liar.
Nicotine is present in the normal diet and everyone tests positive for nicotine. More than 40 clinical studies report that smoking protects against Parkinson's disease. It is tempting to assign the protective effect to nicotine, especially as it shows benefits in treatment of such conditions, but exclusive assignment of this to nicotine alone may be premature (nicotine is an anti-inflammatory; but anatabine for example, another alkaloid present in tobacco, is an even more powerful anti-inflammatory).
The regional or national economic effect of vaping removing smoking revenues will be substantial.
Government, major industries, US cities, US States, and whole economies depend partly on the smoking money machine. If/when that is taken away and the cost of extended pensioner life is added, there will be a massive hole in their budgets. In the UK it is easy to calculate that this will be at least 5% of GDP, and the knock-on effect could even go higher. This is because in a socialised state such as the UK everyone receives free healthcare, pensions and care in old age; if you take away the money that pays for that and simultaneously enable millions of people to live at least 8 years longer into old age, the effect is going to be disastrous. It will be far less dramatic in places where individuals don't receive automatic state pensions and just die if they don't have the funds to pay for treating serious illness or for care in old age.
There are various reports on the current situation with regard to the MSA payments to US States. Some say that these fees had already started to slide at Q2 2014, way ahead of the predicted time this would happen. 2018 was one estimate for the first sign of this effect - but like all estimates for anything to do with ecigs, it could be inaccurate as far as the timescale is concerned. Ecigs are an unstoppable avalanche that will overtake you much sooner than you expected, whoever you are and wherever you live. Take a look at how quickly and dramatically Malcom McClean changed the world if you don't understand this . Han Li  may well do the same, and perhaps even faster.
The pain caused by this economic impact is already being felt: US States' Attorneys General are screaming in protest and demanding action; indeed, some have taken action already by supporting bans on or taxes on ecig products of various kinds in their States and are working hard to protect cigarette sales. Countries like Italy are yelling in agony and have placed huge taxes on ecigs that have absolutely nothing to do with health, in order to replace the lost tobacco tax revenues. In other words they all want to tax the cessation of smoking, to make up for the lost revenues from smoking. This should make the utter hypocrisy and murderous corruption of health policy quite clear to those who thought it might be based on health, or science, or something like that.
There is no health policy in reality - just fiscal policy.
Many jobs in tobacco growing, cigarette making, and distribution/retail will be lost. Retail tobacco shops - tobacconists, in Britain - are going to go out of business unless they have new alternative equally-profitable product lines (such as EVs). An equal number of jobs will be created in EV manufacture since it is a labour-intensive process (perhaps more). The jobs will on balance be transferred to south-east and south Asia as is to be expected, as general manufacture now takes place where labour is cheapest (this is the 'McClean effect' ).
The effect of a switch from burning vegetable matter to battery-powered nebulising should be examined.
Batteries: the lithium cells used in EVs are toxic to the environment when disposed of incorrectly. In general the technology is changing from small cells integral to the device, with a short lifespan, to larger removable cells with a longer lifespan. Over time, it is likely that disposal of old lithium batteries will decrease per 100 units sold, as batteries become larger, more reliable and have a longer lifespan (more recharge cycles). However, this technology improvement will be eclipsed by growing sales, which are already in the tens of millions per year and will reach hundreds of millions per year.
It is doubtful if ecig batteries will ever be disposed of correctly by product-specific recycling. On the other hand this impact can never equal the disastrous, corruption-driven, legally-enforced changeover to 'long-life' lightbulbs in the EU, which has intoduced billions of mercury-containing expired light bulbs into the environment (especially since the description 'long life' is frequently a misnomer). As bulbs will break in the trash disposal process, very large amounts of mercury in total will be released; but batteries are more likely to retain their chemical load. The immense volume of incorrectly disposed-of lightbulbs plus their tendency to break open means that the environmental impact of 'longlife' bulbs is thousands of times worse than the largest possible volume of disposed lithium cells. Old batteries are a problem, but there are many worse issues.
Heads: the technology has changed from atomisers to cartomisers to tanks of various types, in terms of sales volume. The materials used are steel tubes, plastic or glass tanks, very small amounts of nichrome and kanthal heater wire, silica wicks, plus other materials in tiny quantities such as nitrile O-rings and sealants. There is no significant environmental impact from disposal of these materials over and above normal domestic waste.
It is difficult to calculate the effect of removing a significant amount of tobacco production for western consumption in cigarettes. Whatever the final outcome in twenty or thirty years or so, in the West, much will remain for cigarette manufacture for other markets, for non-cigarette products, and for nicotine extraction. Third-world countries do not appear to be able to afford EVs, so smoking will grow in such countries until incomes allow the choice of alternative products.
Some say tobacco agriculture has a negative environmental impact, others it is neutral. The remaining tobacco crops will be mostly found in China and India (also Africa), as that is where cheap cigarette tobaccos are grown and the nicotine extraction takes place, and corresponds with the largest remaining cigarette markets. Small-scale tobacco growing will remain in the USA and EU, addressing high-quality or locale-specific smoked products - there will always be a market for Perfectos Finos or Balkan Sobranie-type cigarette products, but at a fraction of the current size. The cigar market will be unaffected, although in time it might even be positively impacted - cigar smokers are unlikely to be affected in any way, and although vapers may not smoke cigarettes any more, some may now smoke the occasional cigar when they have never done so before.
The global effect due to hundreds of millions of smokers not dying is hardly inconsequential in a time of massive over-population. The planet simply cannot support life indefinitely with the current number of people, never mind any increase.
It is reported that a billion people will die from smoking this century. If they all switched to vaping then very few will die. Leaving aside the likelihood of this happening or not, if a hypothetical situation developed where most/all smokers switched to vaping or started in the first place as vapers and never smoked, it might be seen as an environmental disaster for the planet. The more people who die the better, when a planet is as disastrously over-populated as ours is and no large-scale wars or disease epidemics help reduce the human population.
Keep in mind that Hawking says we only have another 200 years to go before disaster strikes: huge numbers of people mean that all fuels will have run out, all metals run out, the bulk of the population is forced back into the stone age, only an elite have access to metals, plastics and fuels, toxic waste has built up to such a degree that the food chain is irrevocably compromised, new diseases and cancers affect almost everyone, and the entire planet is a toxic waste dump. Others say that time is further off - but it will come one day. Therefore saving a billion lives isn't necessarily a good thing for the planet.
The politics of vaping
One can therefore at least partly sympathise with the Greens, who bloc-vote with the Socialists to ban vaping, as they are in effect voting to save the planet or at least prolong its usefulness to us by enabling an early death for those who choose it or can be forced into it, by the protection of smoking and the removal of all other options.
The Socialists vote to ban vaping, on the other hand, in order to maintain control of the production apparatus, centralise revenue generation, maximise revenues, protect existing revenue channels from independent interlopers, and prolong control of the smoking economy for as long as possible; in other words they vote to kill for profit. Thus an individual smoker or vaper voting Green or Socialist (Democrat is the nearest equivalent in the USA) is voting for their own death, though it is of course their right to do so.
You might say that at an individual level this is murder; but politicians are never convicted of it although their policies clearly cause it (it's called 'desk murder'). The best example of this seems to be the EU, who deliberately kill at least 70,000 European citizens every year in order to protect the smoking economy. The Snus ban most likely prevents at least 10% and perhaps as many as 20% of smokers from switching - note that 66% of those where it is permitted and promoted have done so, e.g. Sweden - so that it is perfectly reasonable to suggest that just 10% of the annual 700,000 claimed as smoking-related deaths in the EU are caused by the ban (at least one genuine expert, Prof Rodu, believes it to be much higher). Mortality associated with Snus consumption is so low that it cannot be reliably measured.
In the UK, it therefore appears that around 10% or more of the 100,000 reported annual smoking-related deaths are caused by the EU, although the UK government is of course complicit in the ban - smoking is a huge revenue generator and cost-saver for government, which is why it is so carefully protected. There was no reduction in smoking in the UK in the 5 years between 2008 and 2013, and in fact the number of smokers grew by about 0.5 million; you are most unlikely to have been told this since it is so well suppressed, and the public perception, carefully crafted, is that smoking is being reduced. The tobacco control industry depend on falsifications of this type in order to maintain their employment. Smoking prevalence started to fall again only in 2014, caused by the switch to vaping: the reduction in smoking closely aligns with the the number who switched or quit via vaping.
Government, together with the pharmaceutical industry, who derive around 15% of their gross income from smoking in the UK, are heavily invested in protecting the status quo. This aligns well with the aims of the tobacco control industry, who are wholly or partly funded by government and/or the pharmaceutical industry depending on location, who can make no further impact on smoking prevalence once the 20% Prevalence Rule operates; although this is never broached in public. Only substitution is efficient after that point (switching to THR products).
These can be summed up in the health, economic and social benefits.
How much an individual benefits from switching from smoking to vaping depends on numerous factors applicable to that individual. Overall we can expect an average of a 100-fold reduction or greater in serious health issues, since it is obvious from the innocuous ingredient profile of ecigs and the lack of any serious health issues so far, with 10 years' use and approaching 100 million-user years experience, that there is no disease factor of any consequence. This does not eliminate issues for those with pre-existing morbidity, genetic predisposition to certain morbities, the possibility of minor to medium severity lung issues for some in the long term, morbidity resulting from abuse, morbidity resulting from contaminated refills, and the nicotine dependence issue.
People do experience benefits from smoking, otherwise they would not smoke. Unfortunately most such benefits are eventually cancelled out by the long-term health impact of smoking. It is well-demonstrated that if smokers quit by age 35, on average no negative health impact can be measured. It is well-demonstrated that smoking protects against some diseases, until the point is reached at which harm equals and then overrides any benefit.
If the smoke is removed then we are left with pure benefit. Clearly, nicotine supplementation prevents some neurodegenerative and auto-immune diseases (this is why at least one is known as 'the non-smokers' disease'). Some vapers will not present with such diseases when, without vaping, they would have done so. Since such diseases are massively harmful and life-changing, this is not an inconsequential effect: preventing hundreds of cases of such diseases is of quite considerable importance. To the individual in a family with a genetic predisposition to such conditions, a method with a significant prophylactic effect that cannot be supplied by any medicine and with none of the negatives associated with smoking is of enormous importance. Indeed, if you have any close knowledge of such families, you will appreciate this rather well. No longer will doctors faced with this dilemma have to secretly advise, as they do, "Two cigarettes a day and no more and no less"; they can state quite openly and honestly: "Vape in moderation".
There are unsupported arguments that (a) nicotine dependence may be created in those using EVs who never smoked; and that (b) such dependence has negative consequences.
There is no evidence whatsoever for any potential for nicotine to create dependence (in humans) without exposure to tobacco smoke or tobacco consumption of some kind. There is no published clinical trial that reports administration of pure nicotine to never-smokers resulted in any measure of reinforcement, dependence or 'addiction' , and there are multiple clinical trials that did exactly this (for various purposes such as testing its benefit for a variety of medical conditions, which, in contrast, has been established) and no dependence potential was reported.
So let's get this absolutely straight, so there is no misunderstanding:
Therefore we can derive two hypotheses from this:
There is a great deal of anecdotal evidence to support the first of these positions, plus a growing body of clinical evidence. There is no evidence whatsoever that nicotine can create dependence without tobacco. In addition it would also be necessary to demonstrate clinically-significant levels of dependence, which is a greater measure of impact than an insignificant number of reports or even a statistically-visible effect. This evidence is clearly extremely difficult or impossible to provide, since it should be easy to locate given the extraordinarily high level of interest in this topic and the number of researchers highly-paid to provide exactly this type of material. The funds on offer to produce this type of work are immense. For example, $850,000 was given to one researcher to watch Youtube videos of vapers in order to construct a pointless study about the harmful appearance of the inhalation methods used. Without a shadow of a doubt, millions will have been offered to produce evidence that pure nicotine can cause dependence in never-smokers. There is none.
Simply because of this anomalous lack of any evidence at all while its existence would be extremely profitable, it is probably reasonable to state that it cannot be demonstrated: nicotine cannot create dependence outside of delivery in tobacco. If by chance it is possible for a small number of individuals unexposed to tobacco, this seems likely to be a statistically-invisible number.
It has been proposed that some individuals may be susceptible to dependence and the actual material or its delivery route are not critically important: such persons are likely to become dependent on something or other sooner or later (this is a theory advanced by some schools of psychology). For example, there are apparently some reported cases of dependence on carrot juice. No doubt if carrot juice could be delivered in a high-power inhalation system and supplied to millions of people, the two or three cases of dependence on record might be doubled.
However, the creation of dependence on nicotine by a high-power high-efficiency managed-profile inhalation vector is an interesting concept. One promising direction for the creation of 'brand loyalty' appears to be the provision of high-power devices with a refill that includes plenty of WTAs, raw aldehydes, and a propensity to form further aldehydes with the application of heat. No doubt the cigarette trade will examine such a direction. We might hope that regulations could eventually prevent such manipulation of the ingredient profile - but regulations clearly have nothing to do with safety and public health, and everything to do with protecting tobacco tax revenues and profitable levels of disease.
In total we should expect that the average individual will experience a huge reduction in risk when switching from smoking to vaping. The actual incidence of subsequent disease will align with past smoking history rather than current vaping habits; risk of presenting with a smoking-related disease reduces over time and depends mostly on how much was smoked and for how long. Lung cancer that appears related to smoking can appear 20 years after smoking cessation, though cardiac event risk decreases more rapidly.
People can expect to save a substantial amount of money when vaping as compared to smoking - provided that low-cost choices are made and the environment allows. This cost-saving is part of the problem for the state.
It depends on the cost of smoking (the tax levels), as well as the product choices made and the regulatory climate. If all factors are suboptimal then it is possible that the cost may be higher: it certainly will be for example if cigarette tax is low, if the vaper uses prefilled cartos on a mini ecig, and if the law imposes excessive costs (taxes and/or regulatory compliance conditions) that are unrelated to actual health impact (as all additional taxation is and virtually all regulation is, in this area).
Therefore the individual may need to make specific choices in order to save money: use of refillable devices, and/or use of DIY refills, and buying on the black market if/when the regulatory/taxation climate becomes unrealistic in order to protect the smoking economy .
Vaping is not smoking, and the health and economic benefits are reflected in improved social standing for the individual. In a climate where a smoker is regarded as abnormal and even anti-social, not smoking is an improvement in social status.
One of the key issues connected with growing EV (electronic vapouriser) sales is the effect of large numbers of non-smokers initiating use. This will inevitably become a major topic for debate when significant numbers of people start vaping without previous smoking - as they inevitably will if the Swedish scenario is repeated, as seems likely.
We can clearly see the effect where it has happened before: in Sweden, tobacco users both switched from smoking to Snus and also initiated with Snus, with the user statistics at 2013 showing that there are now twice as many Snusers as smokers, and that male smoking prevalence is reducing dramatically by 1% per year and has done so since 2003 when it was 17%, with a uniquely-low 5% male prevalence therefore expected by 2016.
Four things are abundantly clear:
A smoker who switches to Snus becomes a non-smoker in terms of the health outcomes: on average there is no significant difference between quitting totally and switching. The same may or may not be true of vaping; it seems possible that the additional risk of lung issues will be cancelled out by the virtual impossibility of any form of cancer since there is no smoke, and no tobacco carcinogens are present above trace values. Therefore even the almost invisible number of cases of cancer attributed to Snus consumption, which are too small to be statistically identifiable, would not be present among vapers.
Nicotine consumption has no clinical significance. If smokers switch to clean nicotine delivery systems the only result is huge gains for public health. If non-smokers initiate with vaping and continue, the public health impact is invisible. At an individual level, there are benefits to nicotine supplementation that outweigh any possible negatives, for a percentage of the population (those who require nicotine supplementation to assist cognitive function; those who would otherwise present with an auto-immune disease; those who might develop early Alzheimers or Parkinsons; and those who can mitigate the symptoms of such diseases with additional nicotine). For the rest, it is no different to any other enjoyable but virtually harmless habit. Although nicotine has been described as a 'wonder drug', it is more likely that it is simply an active dietary ingredient that some miss out on due to erroneous and damaging propaganda.
The principal questions
The main question, then, is whether something that is clearly massively beneficial for the individual and for public health is a benefit for society in every way. There are many possible issues such as the major ones: the economic impact, and if gains for the individual are also gains for society and/or the planet; and the rather minor ones by comparison including the exact potential of nicotine for dependence when delivered in a highly efficient system even without previous exposure to tobacco; and if there is any such potential, whether a harmless dependence is of any consequence when placed alongside all the other such dependencies in modern urban lifestyles, especially set against the significant benefits for some.
The impossibility of predicting scale
It is impossible to guess at some issues and especially the scale: if someone had stated in public a guess at even one-hundredth of the effect on the UK of containerised shipping in 1975, they would have been dismissed as a lunatic. Containerisation drastically changed the UK to an extent that is probably still not appreciated even today . Indeed, some of its obvious effects have been attributed to Mrs Thatcher, an achievement (or destructive effect) impossible even for a Prime Minister.
These things are clear enough with hindsight - given enough distance - but impossible to predict at the time. Or perhaps, guessed at but kept quiet by those who may envisage some of the results, in order to avoid being called crazy.
Timescales: new tech vs the old
What we do know is that we face at least another 20 years of bitter strife as the new technology replaces the old, and the beneficiaries of the old system fight desperately for survival (as they always do - they have to). The key issue in this war is that those in power benefit hugely from smoking, and therefore the changeover will be a vicious and bloody war of the powerful versus the population, in which the public are forced to smoke and die whether they want to or not and until such time as they can sweep away the oppression.
This is a UK-centric evaluation and some adjustment may need to be made if specifics are applied to other countries.
An attempt has been made to provide a balance between the positive and negative effects of THR. If you feel the balance is unfairly weighted at any point, please use our Contact page and point out where and why - thank you.
Numbers are written numerically e.g. 3, not three, to make them easier to locate and compare.
References for all statements of fact or evidential citations are given on the References pages accessed from the right-hand menu. Only those points that may not be clear to those new to the debate are clarified in the notes below.
More citations are always welcome - thank you.
 Snus is the local oral tobacco of Sweden. Because it has been used for over 100 years and has been intensively studied for more than 30 years, the facts of its use are clear. Sweden's national health statistics are unique, as a direct result.
The data resource on smoke-free tobacco use and long-term nicotine use without smoke is of vast size (hundreds of clinical studies and an unequalled raft of incontestible facts), and now used for such purposes as long-term NRT licensing applications, since the NRT data resource is tiny in comparison.
Men mostly use Snus. Male smoking prevalence was 17% in 2003 and has fallen at 1% every year since then, and is expected to reach 5% by 2016. Female smoking prevalence is a few points higher, but continually being dragged downward by the male/Snus effect (very few males smoking, and this number reducing year on year, may result in a denormalisation of smoking that has lead to the low female smoking rates even when women do not switch to Snus). Sweden may be the only country to have a male smoking prevalence lower than the female. Sweden was the first EU country to break the 20% prevalence barrier and will be the first country to reach the 5% overall smoking prevalence level one day - the level said to be 'an insignificant smoking prevalence' - perhaps by around 2020. Currently this seems impossible for any other country, by any date (restrictions on smoking are a device probably designed to operate in name only; they simply lead to more smuggling in order to supply the demand, which stays static once the 20% Prevalence Rule operates).
Sweden provides us with the foundation for THR science: Sweden's national health statistics are unique. Sweden has the lowest tobacco-related mortality of any developed country by a wide margin, and the lowest male lung cancer and oral cancer rate in the EU. Bans on Snus in other countries are therefore rather obviously kept in place for economic reasons since such bans are clearly enormously harmful to public health: they keep smoking disease and death rates high for economic advantage.
 The world authority on the oral pathology of tobacco consumption is Prof Brad Rodu, whose work should be consulted on these issues.
 The CDC has recently hidden all health statistics related to smokeless tobacco consumption by avoiding the collection of this data, and by not publishing reports that specifically collected such data (the same being true of positive research on nicotine, which has been deliberately withdrawn from public view). This is believed to coincide with the lack of any demonstrable health impact from modern US ST products, which align more closely with Swedish Snus in their health risks rather than with historic products, and is unacceptable to the CDC's ideology and/or commercial aims. In addition they have deliberately misrepresented statistics on ecig use particularly with regard to youth use (or non-use). Thus, their statistical presentation in this area can be described as fraudulent.
 For example, the Mayo Clinic published a study in which they reported some significant health concerns for extended coffee consumption. On the other hand, Mayo appear to think that anything apart from staying in bed is seriously harmful, so perhaps this needs to be taken into account.
 Auto-immune / inflammatory diseases, neurodegenerative diseases such as Alzheimers and Parkinsons, cognitive dysfunction (multiple separate types).
 Han Li is his own preferred Latinised spelling of his name, often seen written as Hon Lik in the past - see the board of directors of Dragonite.
 The current use of the term 'addiction' means dependence plus harm as a result. This cannot be applied to nicotine since we have absolute proof that consumption of nicotine without tobacco smoke causes no clinically-significant elevation of risk for any medical condition. A consumer of nicotine is probably at less risk than a consumer of coffee, with equal relative levels of consumption. For example, roast coffee contains about 1,000 compounds, only about 30 of which have been tested for carcinogenic potential, and more than half tested positive. Nicotine is not associated with cancer (in humans) in any way and there is absolute proof of this.
 To provide the maximum possible benefit to public health, ecigs should be tax-free in order to assist smokers to switch; and the only factor that requires regulation over and above normal consumer protections is refill liquid quality. So far, all regulatory proposals have avoided refill quality provisions and concentrated on factors that will reduce EV sales for no discernible health benefit, revealing that the basis of ecig regulation is to protect cigarette sales (in practice, most often in order to protect tobacco tax revenue and pharmaceutical industry income) rather than to improve safety.