Gold Rush: Measuring Nicotine Mortality by the Millimeter

 

The New Yorker magazine recently published an article, “Zyn and the New Nicotine Gold Rush,”  that included a remarkable passage from a discussion between the author and Thomas Ericsson, a former Swedish Match employee.  It perfectly describes the risks of using snus and nicotine. 

“I asked Ericsson whether he had any concerns about the possible harms of nicotine itself. ‘Of course you should have concerns,’ he told me. ‘Or you should do risk analysis.’ He walked out of the room and returned with a large ball of string. The string was exactly ninety-five metres long, each millimetre representing one of Sweden’s approximate ninety-five thousand annual deaths. Ericsson slowly unravelled the string until he reached a piece of tape representing the people who die early from smoking each year. He moved his fingers down to another marker, a few meters shorter, which represented the people who die from drinking. He continued shortening the string, indicating the number of deaths by suicide (fifteen hundred), drowning (a hundred and fifty), car accidents (two hundred), and workplace accidents (between fifty and seventy).

“‘You can ask yourself, What are Swedish people most afraid of? They’re afraid to fly. They’re afraid of wolves. They’re afraid of deer and other things,’ he said, holding a short length of string. ‘But what you should be afraid of is the wasp. It kills five to ten people every year.’ Finally, Ericsson reached the very tip of the string. While working on Nicorette, he and his colleagues did a risk-analysis calculation that estimated that fewer than two people per year would die of heart illnesses exacerbated by nicotine use. Compared with other hazards, he said, ‘this is not a big risk.’”

I have recognized the minuscule risks of snus since 1995, when I first described the Swedish experience in a peer-reviewed publication:

“Sweden has been the world's largest per capita consumer of smokeless tobacco (ST) throughout the 20th century, without a resultant oral cancer epidemic.  On the contrary, the age-adjusted mortality rate for oral cancer from 1960 to 1990 in Sweden was low and remarkably stable at 2.3 to 3.6 per 100,000 person-years.  A retrospective study of 200,000 male snuff dippers in Sweden found only one case of oral cancer per year.  This is in marked contrast to most other European countries where ST use is essentially nonexistent and where increases in oral cancer mortality have mirrored earlier increases in cigarette consumption.  The greatest increase in oral cancer mortality has occurred in France (13.4/100,000 person-years in 1955-59 to 32.3/100,000 person-years in 1985-89). 

“It is not surprising to find that Swedish lung cancer mortality rates have been the lowest in Europe over the past 40 years.  These large scale vital statistics from Sweden and France strongly support the suggestion that if tobacco is to be used, it should be in the form of ST and not cigarettes. The population that uses ST in lieu of smoking is, in effect, protected from lung cancer and other major smoking-related diseases and suffers little or no increased risk of oral cancer.” (emphasis added, references removed)

In 2004, following my research sabbatical at Sweden’s Umeå University, I published this:

Rodu B, Cole P.  The burden of mortality from smoking: comparing Sweden with other countries in the European Union.  European Journal of Epidemiology 19: 129-131, 2004. https://www.ncbi.nlm.nih.gov/pubmed/15074568  

In that article, epidemiologist Philip Cole and I described “the mortality currently attributable to smoking in the European Union (EU), and the change that would result if all EU countries had the smoking prevalence of Sweden.  Almost 500,000 smoking-attributable deaths occur annually among men in the EU; about 200,000 would be avoided at Swedish smoking rates.”

More than 20 years after our estimates were published, the Swedish Tobacco Experience has become a Gold Rush, meaning that more people are consuming nicotine and tobacco in a safer fashion.

5 Vaping “Facts” You Don’t Want to Know

 

Dr. Michael Blaha, Director of Clinical Research at the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, has published an article titled, “5 Vaping Facts You Need to Know.”  The piece contains a number of glaring falsehoods.

I should note my profound disappointment with this article, as Dr. Blaha recently joined me and Sally Satel as faculty members of the since-cancelled Medscape medical education course on tobacco harm reduction (THR).  Despite Dr. Blaha’s involvement with the tobacco-prohibitionist American Heart Association, I appreciated his cooperative attitude and moderate opinions.  The shortcomings of his subsequent article are all the more disappointing.

Here are highlights from Dr. Blaha’s piece, followed by my corrections.

1. “Vaping is less harmful than smoking, but it’s still not safe.”

While Dr. Blaha acknowledges “that vaping exposes you to fewer toxic chemicals than smoking traditional cigarettes,” he follows with five paragraphs on the CDC-labeled subject of e-cigarette or vaping use-associated lung injury (EVALI).  This is grossly misleading, as the cause of EVALI was identified years ago as illicit marijuana

2. “Research suggests vaping is bad for your heart and lungs.”  

Dr. Blaha states what every health professional should know: Nicotine is addictive, and it “raises your blood pressure and spikes your adrenaline, which increases your heart rate…”  But he doesn’t include the critical phrase, “transiently, while you’re using it.”  He then cites studies claiming associations of vaping and lung/heart diseases, most of which have been demonstrated by my research team as unreliable or bogus (here, here and here)

3. “Electronic cigarettes are just as addictive as traditional ones.”

Here Dr. Blaha ignores the fact that nicotine is no more harmful than caffeine, which is also addictive.  Further, he claims, “many e-cigarette users get even more nicotine than they would from a combustible tobacco product: Users can buy extra-strength cartridges, which have a higher concentration of nicotine, or increase the e-cigarette’s voltage to get a greater hit of the substance.”  This is irrelevant, as all tobacco users titrate their dose for satisfaction and enjoyment.

4. “Electronic cigarettes aren’t the best smoking cessation tool.”

This is false.  Population evidence that smokers are switching has been ignored for years by federal officials and others (here and here).  I disagree with Dr. Blaha about the need for consumer vaping products to be proven in clinical trials (here), but two smoking cessation trials, published in the New England Journal of Medicine in 2019 and 2024, clearly demonstrate that vapor products outperformed Dr. Blaha’s preferred “FDA-approved smoking cessation options.”

5. “A new generation is getting hooked on nicotine.”

This is another falsehood.  I have demonstrated that only a tiny fraction of high school vapers are at risk of nicotine addiction and have not used other tobacco products (here). 

6. “Getting hooked on nicotine often leads to using traditional tobacco products down the road.”

No.  Federal surveys show that the minuscule smoking rates among high schoolers is being maintained by young adults (here).

One could surmise from Dr. Blaha’s concerns about why e-cigarettes are attractive to young people that the following steps should be taken:

·       Because many teens believe vaping is less harmful than smoking, we should lie to them.

·       Since e-cigarettes have a lower cost-per-use than traditional cigarettes, we should raise prices.

·       As e-cigarettes have no smell, thereby reducing the stigma of using tobacco, we should make them stink.

None of the above make sense, as all the facts about vaping show there is no youth vaping crisis to fix.

President-elect Donald Trump has nominated Dr. Blaha’s Johns Hopkins colleague Dr. Marty Makary to be FDA Commissioner.  I hope Dr. Blaha’s article isn’t his application to be Director of the FDA Center for Tobacco Products.