Tobacco Harm Reduction: Hope in the U.S., Despair in Europe

In my commentary, “The Electronic Future of Cigarettes,” published last week in The Atlantic,  I described “…a radical transformation in the way our society uses tobacco…as tobacco consumers switch to smoke-free products like smokeless tobacco and e-cigarettes.”  One of my longstanding goals has been to correct decades of misinformation about nicotine and tobacco, in order to introduce safer smoke-free products to millions of smokers. 

The Atlantic article, available here and reproduced below, conveys a hopeful message, but optimism in the U.S. is offset by depressing events in Europe.  The British Government two weeks ago decided to regulate e-cigarettes as medicines (here), a move that will likely deter wider e-cig adoption by smokers.  The European Union continues to move forward with its tobacco directive, which denies vastly safer snus to all but Swedish smokers and places further restrictions on e-cigarettes. 

A blistering public health critique of the European Commission, the European Council and the Irish Presidency, the World Health Organization, the European public health lobby and various governmental health organizations is offered by Clive Bates in his recent web post (here).  

The Electronic Future of Cigarettes

Aiming for a tobacco-free society is myopic. Embrace the safer alternative.

Brad Rodu

The Atlantic, June 20, 2013

We are on the cusp of a radical transformation in the way our society uses tobacco. Cigarette consumption is in substantial, protracted decline as tobacco consumers switch to smoke-free products like smokeless tobacco and e-cigarettes.

This isn't America's first large-scale change in tobacco habits; in the early 1900s, cigarettes replaced chewing tobacco. This is, however, the first shift with a promising public health outcome. The reason is simple science: Smoke-free tobacco and nicotine products are around 98 percent safer than traditional cigarettes. 

The evidence has been mounting for a long time. I published my first scientific studies on vastly safer smoke-free cigarette substitutes almost 20 years ago. Britain's Royal College of Physicians, one of the world's oldest and most prestigious medical societies, reported in 2002: "As a way of using nicotine, the consumption of non-combustible [smokeless] tobacco is on the order of 10-1,000 times less hazardous than smoking, depending on the product." The report continued with an even bolder statement, acknowledging that some smokeless manufacturers may want to market their products "as a 'harm reduction' option for nicotine users, and they may find support for that in the public health community."

In 2007, the Royal College challenged governments to consider "...that smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved."

Big tobacco companies are already adapting to the demand for smoke-free tobacco. Altria, the largest American cigarette manufacturer, will sell e-cigarettes throughout Indiana in August. Number two Reynolds American believes that "governments, public health officials, tobacco manufacturers and others share a responsibility to provide adult tobacco consumers with accurate information about the various health risks and comparative risks associated with the use of different tobacco and nicotine products." Reynolds sells Snus, a smokeless tobacco product that has produced an extraordinarily low smoking rate in Sweden, under its flagship Camel brand. Reynolds also introduced dissolvable tobacco products, and it owns a pharmaceutical company that sells nicotine gum. In July Reynolds will start selling its Vuse e-cigarettes in Colorado.

Lorillard, the nation's third largest cigarette maker, is taking an aggressive smoke-free posture in the public policy arena as it promotes its Blu e-cigarette brand. Lorillard CEO Murray Kessler wrote, "We see e-cigarettes as a product that has the potential to play a critical role in the national harm reduction discussion and affords our company a seat at the table in this debate."

Sadly, the potential of tobacco harm reduction is threatened by opposition from many major medical organizations and government agencies. Obsessed with a myopic vision of a tobacco-free society, they have transformed a legitimate war on smoking into a moral crusade against tobacco, a mistake that was tragically made with alcohol almost 100 years ago.

Congress has prohibited tobacco marketers from any communication with smokers regarding safer alternatives without the express approval of the FDA. So far, the agency has taken a hard line, claiming, falsely, that, "To date, no tobacco products have been scientifically proven to reduce risk of tobacco-related disease, improve safety or cause less harm than other tobacco products." The agency is defying a key element of its stated mission - "to provide the American public with factual and accurate information about tobacco products."

In an effort to kill the nascent smoke-free market, the FDA is slow-walking development of necessary regulations. In March 2012, it signaled the extraordinary lengths that companies will have to go to in order to have a product accepted as "modified [i.e., reduced] risk. In essence, the agency will require dozens of new studies on minute product details and human effects, which will likely take a decade or more.

This is regulatory fundamentalism, a bureaucratic maze that will condemn e-cigarettes and smokeless tobacco products, and therefore tobacco harm reduction, to purgatory. With this delay, cigarettes will continue to dominate the American tobacco market, and 440,000 more Americans will die from smoking-related disease every year.

One thousand two hundred and five deaths. Every. Single. Day.

The body of highly credible research and roster of public health experts endorsing tobacco harm reduction continues to grow, providing more science-based support for smokers to switch. In the absence of rational FDA regulation, nicotine-addicted smokers would do well to quit cigarettes and avail themselves of the many smoke-free harm reduction products that are currently on the market.

European Experts Continue to Ignore the Swedish Miracle

A new study by cancer epidemiologists clearly provides evidence that snus use among men in Sweden is responsible for the lowest cancer death rate on the European continent. Surprisingly, the authors avoid drawing this obvious conclusion in both their article and their press release.

The study examined cancer mortality trends in 34 European countries over the period 1975-2004. It found that cancer deaths among men throughout Europe declined, mainly due to a drop in “lung and other tobacco-related cancers,” according to co-author Cristina Bosetti. The study shows that men in Sweden have the lowest death rates for lung cancer (less than 50% of the European Union rate) and for all cancers, while rates for Swedish women are at or above EU averages.

These findings are fully consistent with my recently published study of European lung cancer, which I discussed in a recent blog post.

The authors of the new study recognize that differences in cancer death rates among European countries reflect differences in smoking; they conclude that “further reduction of tobacco smoking remains the key priority for cancer control in Europe.” That’s perfectly true. But why did the authors ignore the only legitimate explanation of low cancer rates for Swedish men: the miracle of tobacco harm reduction?

It is important to point out that the difference in cancer rates between Swedish men and the rest of Europe is not a new finding. The first author of the current study, Carlo La Vecchia, is a prolific epidemiologist who previously published a study of cancer in Europe during the period 1955-1989. That study clearly shows that Swedish men have always had the lowest lung cancer rates on the continent.

When that study was published in 1992, there was little appreciation, either in Sweden or elsewhere, of the effect of snus use on smoking. But now there is a wealth of scientific literature on the Swedish miracle. When epidemiologists, tobacco researchers, policy experts and government regulators purposefully avoid talking about tobacco harm reduction, they put their reputations in jeopardy, to speak nothing of the lives of millions of smokers.