What the EU Snus Ban Means: 290,865 Casualties Per Year

A November 12 e-cigarette summit at the Royal Society in London featured a range of views on European prospects for these new products (information here). 

Tobacco harm reduction proponents included Clive Bates, Robert West, Jacques Le Houezec, Konstantinos Farsalinos, Jean Francois Etter and Antoine Flahault.  One presenter summarized the Swedish experience with snus as population-level proof that safer smoke-free products save lives.  He used my published study (abstract here) showing that there were 172,000 deaths from lung cancer – the sentinel disease of smoking – in the European Union in 2002.  If all men in the EU had smoked like Swedes, there would have been only 80,000 lung cancer deaths.

A summit attendee asked if I could update that analysis with more recent data.  In fact, the World Health Organization and the International Agency for Research on Cancer now have 2009 lung cancer mortality information for 27 of the 28 EU countries (Cyprus is the only exception).  I have calculated the number of lung cancer deaths among men that would have occurred at Swedish smoking rates for all of these countries.

Sweden’s lung cancer rate is still the lowest in the EU by a long shot, at 68 deaths per 100,000 men age 45+ years.  Finland’s is the next lowest at 102, which is interesting because snus is still used in some parts of that country, despite its prohibition.  In contrast, Hungary and Poland have the highest rates, at 278 and 222 respectively.

For perspective, two non-EU countries are worth mentioning.  The lung cancer mortality rate in Norway, where snus has contributed to reduced smoking (discussed here and here) was 121, which would have been fourth in the EU. The rate in the U.S., where tobacco harm reduction has been trashed by prohibitionists, was 138, which would have placed it tenth, behind Sweden. 

In the EU, the 2009 Swedish lung cancer rate was 12% lower than in 2002.  This is consistent with declines in most countries’ rates, ranging from -3% in Hungary (from 287 in 2002 to 278 in 2009) to -20% in Estonia (from 227 to 181) and Malta (from 158 to 126). 

While the declines may appear modest or even impressive, the lung cancer death toll among European men of 183,423 is intolerable.  The EU continues to ban snus everywhere except Sweden.  The price for this appalling policy: 99,086 avoidable lung cancer deaths per year, plus more from other smoking-related diseases.

Considering that 91% of lung cancer deaths are attributed to smoking, and lung cancer accounts for only 31% of all smoking-attributable deaths among men in the EU, the toll from smoking among men in these EU countries is 538,435.

At the Swedish rate, the toll would be 247,570.  That makes the net cost of the EU snus ban 290,865 deaths (assuming that all EU male smokers would adopt snus as successfully as Swedish males).

Recently the European Parliament voted on a new tobacco directive; the results make smokers both losers and winners.  Parliament continued the snus ban but struck down a provision that would have suppressed e-cigarette access.  As Clive Bates noted (here), “…the snus ban tells us that evidence, analysis and even concern for human life are not always that influential in way the EU makes policy.”     

The EU snus ban is indefensible and immoral. 

Lung Cancer Mortality Rates*, Numbers of Deaths, and Numbers Expected at Swedish Rates Among Men 45+ Years in 27 European Countries, 2009
Country	Rate*	Deaths	Deaths at Swedish Rate
Austria	120.3	2,360	1,334
Belgium	176.8	4,851	1,866
Bulgaria	157.8	2,633	1,135
Croatia	213	2,153	687
Czech Republic	176.7	3,950	1,520
Denmark	129.8	1,859	974
Estonia	180.6	475	179
Finland	102	1,426	951
France	152.9	21,983	9,777
Germany	126.8	28,839	15,466
Greece	176.6	5,280	2,033
Hungary	277.8	5,605	1372
Ireland	124.4	1,055	577
Italy	139.8	25,146	12,231
Latvia	192.5	833	294
Lithuania	188.6	1,139	411
Luxembourg	145.7	154	72
Malta	126	124	67
Poland	221.8	16,250	4,982
Portugal	105.3	2,646	1,709
Romania	182.7	7,528	2,802
Slovakia	167.6	1,567	636
Slovenia	157.5	723	312
Spain	157.9	17,061	7,347
Sweden	68	1,820	1,820
The Netherlands	156.8	6,368	2,762
United Kingdom	120.9	19,595	11,021
All		183,423	84,337

*Deaths per 100,000 men per year, age-adjusted to the World Standard Population.
Note: Croatia was not an EU member in 2009.  

Australia: Tobacco Control and Bootlegger Paradise

Australia is the darling of anti-tobacco extremists.  They tout that country as the model for draconian cigarette regulation and taxation.  Australia imposed mandatory plain packaging last December, and exorbitant excise taxes have raised the price of a pack of cigarettes to 16 Australian dollars (AUD). 

A new report (here) from KPMG tracks the effect of these policies on smoking prevalence and consumption.  The unintended consequences remind one of America’s Prohibition Era fiasco.

KPMG compares Australia’s exorbitant per-pack prices with those of other countries in the region (all in AUD), including Cambodia (1.12), Vietnam (1.08), Indonesia (1.43), Thailand (3.07) and Papua New Guinea (5.37).  It comes as no surprise that these differences have created a huge illicit market in Australia, accounting for about 13% of all cigarette consumption. 

The Aussie black market offers smokers an array of smuggled products.  Counterfeit cigarettes are inferior products manufactured offshore and packaged to resemble popular brands.  KPMG also identifies a type of contraband cigarette called “illicit white” which is produced specifically for smuggling.  One such brand, Manchester, is so popular that it has a market share of 1.3%.  In 2012, Manchester was only found in Sydney and Melbourne; this year it was available in 13 of the 16 cities surveyed by KPMG. 

I discussed earlier this year how prohibitive policies and prices in New York (population 20 million) have cost the state a quarter billion dollars that wound up in criminal hands (here).  In Australia (population 23 million), the toll is larger: KPMG estimates that the government has lost $1 billion in excise taxes to the black market.

In their popular book Freakonomics Steven Levitt and Stephen Dubner argue that “Morality…represents the way that people would like the world to work – whereas economics represents how it actually does work.” (emphasis in original) 

Australia’s treatment of smoking as a moral issue has resulted in Prohibition-Era tobacco policies and real-world economic consequences.

Misinformation From Federal Officials, 2013 Edition

“See, in my line of work,” said President George W. Bush in 2005, “you got to keep repeating things over and over and over again for the truth to sink in, to kind of catapult the propaganda.”

Confusing truth with propaganda is a chronic disease among federal officials.

I documented in 2010 that three FDA appointees repeatedly conflated “tobacco” and “smoking” in a high-profile New England Journal of Medicine article (here).  Three years later, federal officials are still distorting the truth. 

Mitch Zeller, director of the FDA Center for Tobacco Products, supplied these appalling comments in a November 6 Robert Wood Johnson Foundation interview:

“It’s really stunning that in 2013 – with everything that we know about the harms associated with TOBACCO use – that it remains the leading cause of preventable death and disease both in this country and globally.” (emphasis added)

Stunning, indeed, but the fact is that smoking is the killer, not tobacco.  Zeller knows the truth. He has spent over 30 years working on tobacco issues, as associate commissioner and director of FDA’s first Office of Tobacco Programs, at the American Legacy Foundation, and as a vice president at the influential consulting group Pinney and Associates. 

Zeller, in the same interview, did acknowledge the continuum of risk: “there are different nicotine containing and nicotine delivering products that pose different levels of risk to the individual.  Right now the overwhelming majority of people seeking nicotine are getting it from the deadliest and most toxic delivery system, and that’s the conventional cigarette.”  Having recognized this, FDA officials should stop using TOBACCO as a synonym for smoking.

CDC Director Dr. Tom Frieden also suffers from the fact-vs.-propaganda flu when it comes to tobacco and smoking.  In a recent interview with USA Today, he said:

“We work 24/7 protecting Americans from threats, whether these threats are from this country or anywhere in the world, whether they are natural or man-made, whether they are infectious or chronic.  Overall, if you look at what’s making Americans sick and killing us, TOBACCO remains, unfortunately, the leading cause of preventable death, more than 440,000 people a year, more than 1,000 a day, every single day, are killed by TOBACCO.”

The CDC routinely publishes the exact number of deaths from smoking: it’s currently 392,681 among smokers and 49,400 from secondhand smoke.  But that’s not the number of deaths from TOBACCO.  In truth, the number of deaths attributable to smokeless tobacco is so low that the CDC and the American Cancer Society have never reported it, even though they have the information (here). 

Americans expect their government to protect them from threats; among the most insidious and destructive is intentionally misleading public health statements from federal officials.

Common Sense Solution for Indoor Vaping

E-cigarettes are gaining traction as legitimate harm reduction alternatives for cigarette smokers, but one nagging question persists: Should vaping be permitted in interior public spaces?

With few exceptions, indoor smoking bans, which protect nonsmokers from exposure to thousands of airborne toxins, are now the standard.  Tobacco prohibitionists would extend these measures to cover e-cigarette vapor.  E-cigarette enthusiasts insist they should be able to vape wherever they like, since their products’ vapor is harmless.  I’ll suggest a compromise that will please no one in these polarized factions.

E-cig fans point to scientific evidence that suggests that e-cigarette vapor confers extremely low health risks.  The FDA reports that adverse events related to e-cigarettes are virtually nonexistent (here), and it is unlikely that inhaling a mist of water, propylene glycol or glycerin, nicotine and flavors – even for an extended period – will lead to any medical illness. 

Consumer Advocates for Smoke-Free Alternatives funded a study of e-cigarette aerosols by Igor Burstyn at Drexel University’s Department of Environmental and Occupational Health.  He concluded that “there is no evidence that vaping produces inhalable exposures to contaminants of the aerosol that would warrant health concerns by the standards that are used to ensure safety of workplaces…the aerosol generated during vaping as a whole (contaminants plus declared ingredients), if it were an emission from industrial process, creates personal exposures that would justify surveillance of health among exposed persons in conjunction with investigation of means to keep health effects as low as reasonably achievable.  Exposures of bystanders are likely to be orders of magnitude less, and thus pose no apparent concern.”  Professor Burstyn’s report on his thorough investigation has not yet been published in a peer-reviewed forum.

The problem is that, however innocuous e-cigarette aerosols are, a bystander exposure level that is “orders of magnitude” lower than for vapers is still not zero.  Modern indoor environments are remarkably free of obvious airborne contaminants, such as smoke or noxious odors.  As a society, we frown upon indoor emissions of all types.  Interestingly, unobserved e-cig use is effectively undetectable, as resulting vapors dissipate almost instantly.  Vapers often suggest that indoor e-cig bans will force them outside, where they may return to deadly cigarettes; the reality is they can stay indoors and continue vaping, so long as they are discreet – no one will know.

Still, it is unreasonable for vapers to expect that they will be given a free pass to use e-cigarettes in every interior public space.  The fact that e-cigarette aerosols are low-exposure and low-risk for bystanders does not make a compelling case to allow them.

Vapers should realize that the vast majority of Americans do not use any form of tobacco, are ill-informed at best about e-cigarettes, and are uncomfortable with others exhaling clouds of an unknown substance. 

The Scientific Evidence for E-Cigarettes

I am honored to join Drs. Riccardo Polosa and Pasquale Caponnetto and their colleagues at the University of Catania in Italy as a coauthor of a new scientific article on e-cigarettes published in Harm Reduction Journal (available here).  We scientifically disprove the stated premise of a recent NPR broadcast (here), “…little is known about the potential health effects [of e-cigarettes].”  NPR “expert” Stanton Glantz stated that “e-cigarettes today are the triumph of wishful thinking over data.”  Our publication shows that e-cigarettes are the triumph of scientific evidence over feigned ignorance.

For the benefit of members of the Flat Earth Society, I reproduce our summary here:

“The dream of a tobacco-free, nicotine-free world is just that—a dream. Nicotine’s beneficial effects include correcting problems with concentration, attention and memory, as well as improving symptoms of mood impairments. Keeping such disabilities at bay right now can be much stronger motivation to continue using nicotine than any threats of diseases that may strike years and years in the future.

“Nicotine’s beneficial effects can be controlled, and the detrimental effects of the smoky delivery system can be attenuated, by providing the drug via less hazardous delivery systems. Although more research is needed, e-cigs appear to be effective cigarette substitutes for inveterate smokers, and the health improvements enjoyed by switchers do not differ from those enjoyed by tobacco/nicotine abstainers.

“It is of paramount importance that government and trusted health authorities provide accurate and truthful information about the relative risks of smoking and alternatives to smoking. If the public continues to be misled about the risks of THR products, millions of smokers will be dissuaded from switching to these much less hazardous alternatives. One of us recently wrote that, “It’s time to be honest with the 50 million Americans, and hundreds of millions around the world, who use tobacco. The benefits they get from tobacco are very real. It’s time to abandon the myth that tobacco is devoid of benefits, and to focus on how we can help smokers continue to derive those benefits with a safer delivery system” [reference here].

“In the absence of regulatory standards, it is important that currently marketed products are of high quality. For example, the hardware should be reliable and should produce vapour consistently. The liquids should be manufactured under sanitary conditions and use pharmaceutical grade ingredients, and labels should contain a list of all ingredients and an accurate and standardized description of the nicotine content.

“According to a recent article by CDC researchers, the proportion of U.S. adults who have ever used electronic cigarettes more than quadrupled from 0.6% in 2009 to 2.7% in 2010 with an estimated number of current electronic cigarette users of about 2.5 million [reference here]. Although rigorous studies are required to establish THR potential and long term safety of electronic cigarettes, these figures clearly suggest that smokers are finding these products helpful. If they were ineffective one would not expect the market to take off as it is. Most importantly, even if this THR product proves to be effective for only 25% of the smoking population, it could save millions of lives world-wide over the next ten years.”