An analysis of what ecigs are, and what their health and economic impact is likely to be.
'E-Cigarettes' are smoke-free, tobacco-free, electric/electronic vapourisers designed as a substitute for tobacco cigarettes. They produce a flavoured water-based vapour (technically an aerosol) that usually contains nicotine in selectable strengths. EVs, as they are probably better described (electric/electronic vapourisers), are a clean nicotine delivery system optimised for attractiveness to smokers.
Although in essence they are simply nebulisers, they are specifically engineered to replicate the experience of using a tobacco cigarette, so that several factors are optimised to make them work better as a substitute for smoking. Their principal use is to replace tobacco cigarettes for the purpose of harm reduction. There are also secondary aims, including personal economic benefits and the reduction of smell, smoke, annoyance or harm to others.
EVs can be used as a substitute for cigarettes by someone who considers themself to be an ongoing smoker; or as a device to enable someone to quit smoking by use of an alternative; or as a means to eventually quit nicotine and/or smoke/vapour inhalation altogether. They are unique in this product area for four unprecedented reasons:
1. The tsunami-like rate of uptake by smokers: an unstoppable force that has stunned observers
2. The ability to convince a smoker to quit who did not want to quit at all, something never seen before or even dreamed of in smoking cessation practice
3. The way ecigs work far better in the real world than in clinical trials, a concept so difficult to grasp for researchers that they need to deny it, especially as this is the direct opposite of the licensed therapies that pay their wages
4. The tremendous engagement of the user community, which has come as a shock to commercial rivals and their paid medics, lobbyists and regulators
This area of consumer products is referred to as THR or tobacco harm reduction, as the core purpose is to enable smokers to use far safer products. There is now no need at all to burn tobacco in order to consume nicotine, unless the consumer wishes to make that specific choice. Clean nicotine delivery systems and smokeless tobacco are highly efficient substitutes. The main issue in fact is whether consumers are allowed not to smoke; too many people make too much money from smoking for that to be an automatic right.
They are a mixed blessing. There are benefits and drawbacks in equal measure, weighted toward the individual but with disadvantages to the State. The advantages include:
But the drawbacks include:
Comparison with Snus
In the list of advantages above, much of the same could be said about Swedish Snus, the Swedish local oral tobacco that is processed to remove most of the carcinogens and has had such a tremendous effect on public health there. However, Snus was quickly banned in Europe in the early 1990s, and where it is permitted the rate of uptake has been low and slow. Smokers outside of Sweden, even where permitted to buy Snus, have not grasped the opportunity - in stark contrast to ecigs, where uptake is on an avalanche scale. The exception is Norway, where the great public health benefit of a switch to Snus is starting to be seen.
A crucial difference between Snusers and vapers (ecig users) is that the ecig user community is one of the most engaged and active consumer groups in existence, and both unique and unprecedented in any public health related area. The community absolutely will not accept the corruption of public health policy by rival commercial interests, and this is creating a battle never seen before: consumers refusing to accept being forced to smoke by the commercial actors and tax-hungry politicians who control health and consumer policy.
EVs are neither a medicine nor a tobacco product - they are an entirely new class of consumer product. They don't contain any tobacco, the nicotine could come from any source, and most EVs don't look anything like a cigarette. There is no functional, physical or mechanical connection between a vapouriser and a cigarette. They don't burn vegetable matter and there is no tobacco, no combustion, no ignition and no smoke. Someone who uses an EV is not a smoker, they no longer smoke, and they are an ex-smoker. A low-performance EV can be made to look like a cigarette, but that is incidental.
Perhaps, if we think that EVs will create large scale disease and death, like cigarettes, then there is good reason to slot them conveniently into a high-tax product group in order to recoup state costs and reduce consumption by taxation. Unfortunately this is not just something of a leap of faith, it is impossible; right now it looks as if EVs will kill less people than coffee does. Classing EVs as a medicine or a tobacco product is a simply a convenient way to regulate them out of contention and to protect cigarette and pharmaceutical sales: they are the solution not the problem.
They are a radically new consumer technology that needs quality control of the refill liquids, but normal consumer protections cover all the other aspects (safe packaging, labelling, electrical safety, sales and marketing practices and so on). Of course, if there is no normal, universal consumer protection in terms of all-encompassing consumer product regulations and an efficient local enforcement structure (both limbs are crucial), then that is a different matter; but the first thing needed in such a case is normal consumer product protections.
There are perfectly acceptable and efficient regulatory structures available off-the-shelf if some sort of additional regulatory environment is needed for this new product area: cosmetics and nutritional supplements each have such a system. EVs would probably kill about as many people as cosmetics and nutritional supplements would without proper regulation, so this appears a valid approach. Regulation in excess of this is not related to health, there is a covert agenda operating.
EVs are part of the solution not the problem. Classifying EVs as a tobacco product makes them part of the problem: an illogical reversal of reality, enforced for financial reasons and rather obviously unconnected with health. Either Prof Britton is correct when he states that a population-level switch to EVs would save five million lives just in those alive today just in a small country such as the UK, or he isn't; and no one is disputing it with him.
EVs are the solution, not the problem. Classifying them as a tobacco product prohibits them from solving the problem, and protects cigarette and pharmaceutical sales. It is done as part of a protectionist agenda that has nothing to do with health.
Use of marketing terms
The term 'e-cigarette' was a successful marketing strategy that is no longer appropriate. It is inaccurate, has the wrong connotations, and is a significant negative now that consumers are aware of the product. It will be extremely useful to cigarette firms moving over to EV sales; otherwise, its inaccuracy is not beneficial. You cannot smoke a vapouriser, and an EV user is an ex-smoker who no longer smokes.
How we should regulate EVs
Any other approach than this qualifies as deliberate protection of cigarette sales, tobacco tax revenues, and pharmaceutical industry receipts for the treatment of disease resulting from smoking. If we want to protect these revenue sources then let's just say so, instead of the giant hypocrisy of the current situation. Current smoking cessation programmes are based on gross incompetence, or fraud, depending on your point of view.
The purpose of ecigarette regulation appears to be (a) to protect the vast income channels generated by smoking, and (b) to protect the dysfunctional smoking cessation system which is no threat to those revenues.
The role of the tobacco control industry in e-cigarette regulation
The principal resistance to EVs comes from the tobacco control industry, a sector of the public health industry that is funded in one way or another by smoking and the profits from treating disease caused by smoking. In the USA all the principal 'public health' organisations opposing ecigs receive funding from the pharmaceutical industry and the MSA payments. In the UK such groups are part-funded by the pharmaceutical industry. Often these funds are greenwashed through a third party in order to obfuscate the source or the agenda.
Nobody running any of these groups is paid less than £100k a year, and such a sum would be regarded as pitiful in the USA, where CEOs of such 'charities' may receive over $1 million. There is a clear conflict of interest here because (a) no one votes to have their huge salary cut by means of cutting their sponsors' profits, and (b) no one works to remove their job entirely by destroying the source of their employment. We know that regular tobacco control policies no longer work in many places; and we know that THR is the proven solution to this otherwise intractable problem. Therefore, by deliberately blocking THR, we can clearly see that these pseudo-health organisations are knowingly protecting smoking and their jobs.
In Sweden, smoking (at least, among men) is about to be destroyed by THR: the switch to Snus. Male smoking prevalence falls by 1% per annum and will be just 5% by 2016. Obviously, no one in the 'public health community' is going to vote for the Swedish scenario - when the smoking gravy train is killed off, where will they go? Where will they get another job with such an obscenely large salary? Where else can they be employed at huge cost with zero results to show for it?
This is the short answer to why cancer health groups and the like all need to protect smoking: it is the goose that lays the golden egg. 'Cancer health' organisations don't support ecigs because they would be removing their own jobs.
It depends entirely on what the context or inference is, because this is a question of smokers' and ex-smokers' perceptions, legal definitions, semantics and popular image, and isn't straightforward.
Smokers who use a safer version of a cigarette in order to reduce the harm still consider themselves to be smokers; smokers who want to quit and do so by moving to an alternative product consider they have quit. Thus, even the users themselves cannot agree on the answer to this question.
Perhaps the answer is yes, because smokers who are no longer smoking are ex-smokers and must by definition have ceased smoking. In normal usage between ordinary people, ecigs are for 'not smoking' and there must be an element of 'cessation' in this. It is complicated, though, by the obvious and inarguable reason most smokers switch to ecigs: their motivation is to keep smoking but without the harm; and by the fact that this alternative route is well-established and called 'switching': substituting safer products for combusted cigarettes.
However, apart from the fact that vapers can't agree on this issue, this area of language is strictly defined by law, believe it or not:
This leads to a slightly complex situation where smokers who have completely switched and no longer smoke will either describe themselves as vapers (people who inhale vapour not smoke), or smokers, or ex-smokers; they may tell you they have quit smoking, or they may say they are smokers using a safer product ('e-smokers'). Because the concept of THR is quite new in the UK compared to Sweden or even the USA - both places where smokeless tobacco is popular and therefore people are familiar with the concept of avoiding smoking by using safer products - Britons are not really comfortable yet with the various terms or concepts. Also, since the technology is new, the concepts and the terminology are not clear to most people. Significant consumer, health and economic changes are coming but these are never clear even during the active changeover phase, never mind the early adoption phase where we currently are.
In reality these issues don't matter except to lawyers or academics. Smokers switch to vaping initially because of one or more perceived attractions. In time they may switch 100% or stay as dual-users. Either has health benefits, and what it's called isn't really of any importance to them; it only has any importance to those who wish to ban or restrict ecigs in order to protect cigarette sales, often to protect the vast profits from treating the diseases that result.
A simple question on the surface, this is an exceptionally difficult one to answer because it depends on time and location. At April 2014, the latest data shows that there are over two million UK vapers, and one-third of them are ex-smokers who quit smoking by use of an ecig . These results are from ASH UK surveys and R West's Smoking Toolkit surveys, which are considered accurate due to their longitudinal component and alignment with other data (and also, it must be admitted, that since the sources are core tobacco control organisations, anything beneficial to ecigs is probably correct - and the revelation that a third of ecig users have quit smoking by use of an ecig is significantly higher than expected).
This percentage may not be replicated in other countries, where figures as low as 10% have been quoted. However those may only be rough estimates, since it is generally acknowledged that the UK data is particularly accurate in this area.
The reason why time is an important factor is because there is a 'vaper's journey' that affects the non-smoking numbers: a personal progression that affects product choice, smoking status, and so on.
It is worth pointing out that dual-use (vaping and smoking) is a benefit with EVs, as against that with other products; yet another unique factor on the list. Smokers who cannot quit using any other product, or who have no intention of quitting, often find they vape more and smoke less, eventually leading to cessation of all smoking. In many cases this occurs involuntarily, and the person is no longer a smoker; a situation all but impossible with licensed pharmaceutical products.
In the end, vaping succeeds for some people and fails for others, again subject to a large number of factors. For example in a worst-case scenario, a 31% success rate at 6 months was reported by one survey; but in other circumstances it is not impossible to achieve a 75% success rate at 12 months: when family or friends are closely mentored by an expert user.
As far as the results from clinical trials go, the best thing to do is ignore them since the results are wildly inaccurate: forcing people to accept a suboptimal hardware solution, and a suboptimal refill solution, and isolating them from expert advice, and offering no mentoring, leads to results at least three times worse than seen in the least successful real-world situations. That must be obvious from the huge numbers who have successfully switched 100% to ecig use (or quit smoking if you prefer), since the figure would be minuscule if the clinical trial results are accurate. EVs work far better in the real world than the lab, a difficult concept for some to grasp.
There are several areas connected with ecigs that prove exceptionally difficult to investigate correctly for those normally connected with research on smoking or otherwise ignorant of the specific issues; but instead of admitting an inability to understand the issues, researchers simply publish anomalous results as if they should be considered normal or accurate. This has been seen so many times in so many areas of ecig-related research that it is almost worthy of being considered a norm: studies of EVs will routinely present inaccurate results.
Mentoring is a crucial issue in any smoking cessation or avoidance method including switching to THR products, and especially so with ecig use because it involves use of one of the most complex consumer product ranges in existence. For example there are far more options available than for computers and software: one vendor alone carries a range of over 7,000 refill liquid options. If all refill liquid options could be totalled, then the figure would easily exceed half a million; and with thousands of hardware options, it means there are already millions of possible combinations for any new vaper if they want to find the optimal solution for their particular needs.
And of course, this tremendous variety is one of the keys to the success of the system: individuals vary significantly in their taste and preferences, and there is sufficient choice now to provide a suitable option for everyone. Indeed, the challenge is to locate that perfect solution, which is part of the vaper's journey. Because taste and preferences change over time, especially in the first two or three months, ecig users need a wide choice of products in order to avoid relapse to smoking. Many new ecig users start with a mini or 'cigalike', but upgrade to a more efficient device after a month or so; people generally prefer a tobacco flavour when they start, but often change to a sweet or fruit flavour after a time; they tend to start with average or high-strength nicotine refills and then reduce the strength over time.
It can therefore be quite easily seen that that there is no single solution for any given individual, never mind a population.
A reasonable estimate is 66%. All such figures are pure speculation, but when all the factors are taken into account, a greater than 50% figure is where we find ourselves:
Of course, it is meaningless to discuss a total switch percentage or final switch percentage without any reference to the timescale - we could be talking a hundred years, after all. However, it seems very likely that more than 50% of smokers will have switched, in many Western countries, by 2030 (in 16 years, @2014). Some say much faster than that and perhaps even by 2023 (this is the Godshall/Herzog projection). We will be able to measure this by the annual reduction in smoking prevalence reported by West / ASH, to get perhaps the best figure to judge by - the US figures are deliberately obfuscated, misrepresented and even deliberately hidden by those who control access to them. The CDC have removed all access to statistics on oral tobaccos in order to hide the health benefits of switching, and to be able to claim that, "All tobacco is bad"; a difficult claim to support if modern ST's are revealed as not killing anyone in measurable quantity; and they have deliberately misrepresented the stats on youth take-up of ecigs, to great effect. It appears that US health-related statistics are a tool for commercial use rather than a public property.
The 20% Prevalence Rule tells us that once smoking prevalence has been reduced to around 20% in a developed country where prevalence was originally much higher, commonly at 40% or higher in such countries, then the reduction stalls out and stops. Smoking prevalence stays at around 20% no matter what methods are used to try to reduce it, and no matter how much money is thrown at the problem. As an example, smoking prevalence reduction stalled out at around 20% in the UK in 2008 and has remained there ever since. The ONS tells us clearly that "smoking prevalence remained static for the 5 years from 2008 to 2013" - see References page. In fact, the number of smokers actually grew in the UK during this time, by around 0.5 million, as a result of population growth.
Once the 20% Prevalence Rule operates, it may not even be possible to reduce smoking by 1% in a decade - as we can clearly see from the static figure for 5 years in the UK; it might take several decades to achieve a single percentage point reduction. The only thing that is proven to work at this point is substitution: replacing smoking with an alternative product that appeals to smokers. This is called THR, and is proven by the Swedish example (Sweden is the world leader in reducing smoking prevalence, and the world leader in reducing smoking-related mortality).
In the UK, smoking prevalence began to fall in 2013 as a result of the huge movement into ecigs and away from smoking; this year, 2014, over 1 million people will have quit smoking by use of the ecig just in the UK (the global figure must already be in the millions), and smoking prevalence may now begin to fall by 1% per year (as has been seen for male smoking prevalence in Sweden since 2003). This would have been absolutely impossible without the EV. In fact it looks as if smoking prevalence would have risen in the UK from 2012 onward without the ecig effect.
For the Godshall / Herzog projection to be correct, a greater than 1% per year fall in smoking prevalence will be needed. This is starting to look a possibility: stick sales (cigarette sales volumes) are dropping at 5% or 6% a year, ecig sales volume trebles every 3 years, and ecig user numbers grow at around 50% a year. There has never been a greater threat to the tobacco control industry and that is why they are screaming louder and louder in pain, partly in fear for their own jobs and partly at the behest of their paymasters.
In the UK and similar countries, funds routed through tobacco control are in effect flushed straight down the toilet; it is up to the individual whether this inexcusable waste of taxpayers' money is viewed as fraud or just gross incompetence. Only THR works for reducing smoking prevalence once the 20% Prevalence Rule operates; there are no known exceptions. (See the relevant page on the right-hand menu for details of the Rule.) Some elements of tobacco control need to be retained in order to continue information and education services, and statistical work independent of national services (which in the case of the USA can be clearly seen as thoroughly corrupt); perhaps 1% of current funding levels would achieve this. 99% of 'tobacco control' funding is useless waste (or fraud), since it does nothing of the sort - the number of smokers in the UK, for example, was growing steadily until EVs entered the picture.
Firstly, there will be around twenty years of bitter fighting over the economic issues caused by the destruction of smoking. All opposition to ecigs comes from the economic pressure, as there are no health reasons to prohibit or regulate something 1,000 times safer than smoking, that has more similarities to coffee drinking than tobacco smoking, and that will destroy smoking. The best parallel is to consider a hypothetical situation where we had smoked tea for its nicotine content, then began to change over to drinking it instead; exactly the same issues would exist as for tobacco. Every single aspect of the situation would be identical: the disease, the deathrate, the high taxes, the vast income derived by the pharmaceutical industry, and the entrenched opposition to a new and far safer way of consuming the product. There is nothing intrinsically wrong with tea, just the way it is consumed; you can smoke it or drink it, and it is obvious which should be promoted and which avoided.
The economic issues are paramount and the health issues are irrelevant at public policy level. In twenty years' time these battles will be nearly over, because approaching 15% of the population will be ecig users and see no reason why a pursuit as harmless (or harmful) as coffee drinking should be subject to strict regulation and high taxation. By the 30-year point, vapers will be a sufficiently strong voting bloc to remove arbitrary regulations and taxes. Vaping will be seen in the same light as tea drinking. To a certain extent this depends on the long-term health impact continuing to stay at or near the current level of short term health impact.
We know exactly what the short-term health impact is, with eight years of data so far at April 2014: vaping is around 100,000 times safer than smoking in terms of mortality risk. This is known because no deaths are attributable to ecig use, and the closest link so far is one death from pneumonia in an ecig-using patient with multiple morbidities including emphysema caused by smoking; pneumonia is common in emphysema patients and the link with ecig use is tenuous at best. In contrast, the smoking cessation drug Chantix, introduced at the same time, has caused hundreds of officially-attributed deaths and perhaps thousands unattributed, with more than 10,000 serious adverse events reported to the FDA compared to the 47 for ecigs; and with successful multi-billion dollar lawsuits against Chantix and zero for ecigs. We therefore know that the timescale is not too short for serious health impact to be demonstrated.
Thus, with smoking reputed to cause 100,000 deaths a year in the UK, and ecigs none, we already see a risk reduction of approaching five orders of magnitude, as the impact is reduced to minor coughing issues and the like for new ecig users with an inappropriate choice of product and/or incorrect user technique.
Nobody knows exactly what the long-term health impact will be, which is admittedly a better measure (and realistically the only measure). It is reasonable to assume that some individuals will experience lung issues of some kind, since daily inhalation of chocolate flavour for decades is a completely new risk factor with unknown outcomes. However, it is impossible for ecigs to cause lung cancer, or any other cancer most likely; and there appears to be no other clinically-significant disease factor.
Minor lung issues are likely for a statistically-visible number but not a clinically-significant number; and medium-severity lung issues are a possibility for small numbers not of statistically-identifiable size. Perhaps, after two decades of use, we will see a few cases of COPD Stage 1 or 2 in intolerant individuals, most cases probably being reversible. Apart from that there seem to be few areas of concern for individuals with no previously-existing morbidity.
The two principal areas of concern are black market refills, and patients with pre-existing morbidities. Where existing morbidity affects the lungs there cannot be anything other than an increase of risk. Patients with emphysema or late-stage COPD should not use ecigs, as is rather obvious; the correct THR product for such persons is Snus (which many would already be using were it not for the UK/EU ban).
Some people are highly intolerant to nicotine, just as some appear almost immune to it, and these individuals should exercise caution. There is a factor-10 difference in individual tolerance to nicotine clearly demonstrated within the vaping community, and therefore we can expect some health issues to be revealed as millions of people use tobacco-free consumer nicotine inhalation products for the first time ever, ad lib, for multiple decades.
It is impossible that ecig use is without risk, but the risk to health will probably approximate that for coffee consumption on a like-for-like basis with regard to the volume of consumption. If about 100,000 people die annually from the effects of smoking in a population of 12.5 million smokers (which is around 0.8% of all smokers dying annually), then if all smokers switch to ecigs instead, we could probably expect about 125 - 1,250 deaths a year (around 0.001% to 0.01% of all vapers, annually). A number this size is invisible statistically.
It is difficult to see what the disease factors might be to cause as many as 125 deaths a year, but some mortality is inevitable since that is a fixed cost for any type of consumption even including normal foodstuffs; but the mean reduction in risk compared to smoking is probably of the order of 1,000 or so. There are two principle risk multipliers:
Thus, risk varies between consumers: it is not at all inconceivable that an individual may consciously reduce their risk exposure to 10,000 times lower than that of smoking, while others may not care if their risk is voluntarily adjusted to only 100 times lower than smoking. A consumer given unrestricted product access and truthful, accurate information will be able to positively manage their risk exposure should they wish to do so; but a common problem with regulatory strictures is that it is impossible to (a) buy the desired safer products, and (b) tell the truth about products in the smoking-replacement areas.
THR products are especially affected. Indeed, the law requires specifically that outright lies are promulgated (for example the FDA's requirement that Snus is labelled with messages such as that no tobacco product has been scientifically determined to entail less risk than smoking; this is a blatant lie, and absolutely opposite to the truth). Where deliberate lies and obscuring the truth is required by law (generally in order to protect related industries), risk rises in proportion.
In the UK, Snus is banned in order to protect pharmaceutical industry income by protecting cigarette sales. This causes at least 10,000 deaths a year since a minimum of 10% of the 100,000 smoking-related deaths a year are easily preventable by an expected minimum of 10% of the smoking population switching to Snus.
A regulatory climate can very easily kill, and it certainly does in the THR area. Hundreds of thousands of deaths have been caused by preventing smokers from accessing safer, non-combusted products - the harm is caused by the smoke, not the nicotine.
Regulation is designed to protect the status quo, and obviously has little or nothing to do with health. The regulatory climate is the principal method by which established industries protect themselves from an interloper, and the delaying tactic they will use here in order to maintain incomes for as long as possible (as industry owns the regulatory process). Since states also have the same aims, regulations will be used for as long as possible to stop ecigs destroying existing income channels; but in the end there will be too many ecig-using voters to allow the continued protection of state tax revenues, the cigarette and pharmaceutical industries, and their multitude of beneficiaries.
The economic hit will be substantial, though - ecigs can only turn off the money tap, they cannot replace even a tenth of the income and cost savings that cigarettes generate for an economy. In twenty years we will therefore see tens of millions of vapers, tens of millions less smokers, and significant economic issues for government as a result. Millions will no longer pay tobacco tax; millions will no longer need expensive drug treatments, from chemotherapy to diabetes drugs; and tens of millions will live much longer into old age.
Electronic vapourisers are a tremendous gain for the individual; a huge and almost unprecedented boost for public health; and a potential economic disaster for the State.
 See References page, Smoking - statistics, #11.