Author Archives: Carl V Phillips

Sunoco minimart on Lancaster Ave, a leader in reducing smoking

Price of the new Americanized version of General snus: about $1.60 for a “trial pack” of 10.  Pennsylvania excise tax on low-risk alternatives to smoking:  just what it should be — zero — thanks to the tireless work of Bill Godshall; there is just the regular sales tax.  Coupon in each package: $1.00 off of your next purchase.

Net cost of using General instead of smoking:  <7 cents/pouch, or a quarter the cost of a cheap cigarette.

No, I don’t really have a deep point, other than the local Sunoco C-store near my house is apparently doing more to help reduce smoking than a the “Quit Smoking Now!” hypnosis place up the road — or than the local quitline and other official efforts.

Of course, I am kidding.  The real credit for that goes to Swedish Match.

Maybe my point was to try to make the anti-harm-reduction people’s heads explode, upon learning how attractive the option of THR is here, and to give them something new to post at their silly little “Tobacco Tactics” page.

 

[As anyone coming across this probably knows, this blog is mostly on hold, waiting to see if we want to start using it again.  In the meantime, if you have not discovered our new Anti-THR lie of the day blog, you would probably like that.]

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General Nordic Mint snus: good news for US smokeless users (and smokers who want to quit)

This week, I chanced upon the opportunity to try this new product from Swedish Match North America and learn that it is on its way to the largest chain convenience stores in my area.

[Request to one of my readers from SM:  Could you put me in touch with your local (Philadelphia area) rep to discuss this a bit more.]

The product has been re-engineered for taste to better appeal to the American palate than do existing General products.  It seems like a very appealing product, a huge improvement (at least for this American palate) compared to the existing General mint-ish product, which just tastes like vile medicine to most of us.  There is also a version of the new product without characteristic flavoring, which is presumably a bit Americanized from the unflavored US version of General, which is perfectly good but still a bit un-American in its flavoring.  (For those interested in more and better product assessments, members of the “snus press” were invited to try these in June to generate some buzz, and several reviews appeared.)

More important, though, is the plan to broaden distribution.  Currently I know only a couple of local specialty shops that sell General, while Camel Snus and others are available at every gas station and most every cigarette store.  Many of these others are perfectly good products (we, of course, do not endorse any particular Western smokeless tobacco product over any other – they are all equally good for THR).  But I have heard many people derisively say, “that’s not real snus!” about the RJR product and others, so the new widely-available General, which seems to deliver more nicotine, faster, and from a smaller pouch than Camel, characteristics which likely appeal to many consumers.

The Swedes and Swedophiles have been saying for a year or two, “that should be our market!”, and this will be a good test of whether that works out.  But whether the new product eats Camel’s lunch or RJR stays as strong as ever, the result will be better for consumers, and thus for public health.  Never doubt that a single thoughtful company, trying to better serve its customers, can improve the world.  Indeed, it is the one thing that most often does.

Random thoughts on TabExpo and the future of THR chattering

Last week I (CVP) was at the TabExpo conference in Prague.  It was an interesting experience, though not so much in good ways, unfortunately.  The networking was great, and I had fun and worked out some plans for some very promising projects.  Beyond that, well….  Here are a random collection of thoughts and observations.

I was part of a congress (scientific meeting) that existed alongside a giant trade show that had >100 booths, mostly with merchants trying to sell their contributions production and distribution process for, in almost all cases, cigarettes.  Like most any trade show that includes lots of tangible visible products, it was interesting and fun, if you either liked the underlying business or just temporarily ignored your feelings about it.  The congress, by contrast, had no exciting displays or free beer.  It included most of a day about harm reduction (what I was participating in, of course), along with related sessions on various aspects of regulation, and black markets, and unrelated sessions on various technical topics.

The one thing that was striking about the trade show was the presence of about a half dozen e-cigarette merchants.  That is the good news.  The bad news is that they (all representing Chinese manufacturers, and there to try to recruit new distributors/retailers to buy and brand their OEM products) struck me as about as socially responsible as, well, the average merchant who was there.  That is not to suggest there was anything terrible about them, or about the average merchant there, but to express disappointment:  Not one of them I talked to had any idea there was a tobacco harm reduction movement in West, or had heard of CASAA or other organizations/projects.  I felt like THR was a fairly minor issue in their minds, and was nothing more than one of many selling points for the product, alongside “this one looks like a cigar!” or “we can provide the highest quality packaging!”.

In fact, the only merchant that seemed to be really pushing the health side was selling a substitute product, rather than a THR product: a green tea vaporizer e-cigarette with no tobacco or nicotine.  They were claiming that this product reverses the lung damage done by smoking (or, presumably, breathing the air in China), and have a brochure with pictures of a lung going through stages of becoming less blackened.  Well, obviously they were fake pictures, because even if the health claims were true, lungs are notoriously difficult to photograph while inside the body (wet, dark) and once they are outside the body, they tend to stop getting healthier.  Things like that almost make you sympathize with the FDA regulators.

Still, having e-cigarette hawkers occupy any of the floor space strikes me as a gain compared to the last one of these I was at, two years ago, where I do not think there was any presence.  Maybe it will work as a wake-up call to the other merchants where nothing else will.

[That reminds me of the previous one of these I attended, in Bangkok a couple of years ago.  I forget if I ever blogged about the wild events that week:  The government caved to pressure at the last minute to try to shut it down.  The venue was moved way across town and the merchants were forbidden from showing any consumer products, including images of them, and possibly tobacco leaf itself.  Needless to say, complying with this (on the grounds of a law that is supposed to protect children from seeing evil images — never mind that this was a closed conference that no one could enter without volition and paying a fee, and obviously everyone was adults) was difficult.  Indeed, it apparently failed because near the end of the conference, some local government and QUANGO ANTZ marched in with the local cops they bribed and tried to arrest the conference organizers for violating the rule.

The best part of that story was that the local ANTZ took several hundred school children out of school, paying them some pocket change for their time, and bussed them to the venue to protest along a roadway — it was great to see them what “think of the children” really means to these people.  Some speakers from the congress went out and invited the protesters (the leaders, obviously, not the hireling children) to come in and participate in the harm reduction sessions at the congress — they refused, of course.  The most amusing part of the fiasco that due to the forced withdrawal of the Thai Tobacco Monopoly (which is to say, the government’s large tobacco company — yes, the same government that was trying to shut it down), their huge booth space was filled by the Thai government’s tourism operation, which brought in very young women who stood around in very little clothing and gave out drinks to the attendees, mostly men in suits — yes, this is what the Thai government does to try discourage the reputation that there is anything seedy about Thailand, like the government selling cigarettes.]

Anyway, this week I participated in a panel discussion on THR.  It was kind of odd to not be giving a talk, but just because I am used to headlining does not mean I am not happy to not have to prepare anything!  I decided I would follow my usual self-defeating Cassandra role of being too far ahead of the room to be appreciated, with a single populist message:  The industry is made of up institution-oriented people who are part of the 1% (actually probably mostly in the next two or three percent below that, but you would not know what I meant if I said “the 3%”) and used to dealing with master-of-the-universe types in Geneva, Brussels, Washington, etc., and so is comfortable trying to negotiate with regulators to try to achieve a government-endorsed harm reduction miracle.  And they are optimistic about it working out that way, at least as concerns the US FDA.  But, I argued, the anti-tobacco extremists have enough power over the regulators, despite claims about “science based policy”, that there is little reason for optimism.  I could be wrong, of course, but I cannot summon up much optimism.

I argued that the second-best thing that could realistically happen would be for the industries to fight the regulators to a standstill, so that they cannot take any more anti-THR steps (like the FDA’s attempt to ban e-cigarettes), allowing consumers to continue to learn about THR and switch to low risk products, as is the trend.  The best realistic scenario would be for the elements of the industry that support THR to start working with consumers, treating them like the primary stakeholder they are, to encourage THR.  (Again, it is possible that governments and super-governments could change their tunes and start supporting THR, which would be better still, but I just do not see it happening until consumer THR awareness and action makes it too embarrassing for them to continue their present policies.)

I pointed out that it was indeed Wrong to act, when supposedly acting from the “corporate responsibility” perspective, as if the stakeholders that the industry needs to deal with are the regulators and anti-tobacco busy-bodies.  These are not stakeholders, and calling them that is a perversion of the term by the 1%-types to try to deny that the interests of millions of considers are most important, and they are the really primary stakeholder (with the industries secondary and the others relevant only insofar as they are helping out the primary).

Before I went into that, I led off with an observation asking the audience to consider an open minded person who is concerned with public health, and who was open to attempts by me, other panelists, and others to persuade them that parts of the industry are anxious to be part of the solution to the effects of smoking.  I suggested that we would immediately lose that person if he were to see one particular image from the congress and hear one soundbite spoken at the expo’s main dinner event.  And there were several other candidates for damning observations if those were not available.  I am not talking about things that would just cause ANTZ to go crazy (“Lord have mercy! look at those evil people who are trying to sell improved logistics control processes! and they are smoking indoors!!!!”), but rather things that would trouble an honest observer.  These do not, of course, change the fact that there are positive efforts from within the industry (I was there for a day of talks about harm reduction, after all), but optics matter.

[Oh, and sorry:  I am not going to report exactly what I am referring to.  While I doubt that anyone from ANTZland reads this blog regularly (since they are usually deathly afraid of being exposed to any ideas that might threaten their cherished faith), I suspect that it is periodically mined by those who consider “research” to be a word for “hunt up anything we can find that, when cited out of context, will support our cause”.  It was fairly interesting, though, so anyone who talks to me personally might want to ask me about it and apologies to the rest of you.]

The low point of the meeting was listening to one of the presenters, who tried to summarize THR, getting wrong about 15% of what he said, and implying that the rest of it was somehow new and original innovation even though it was nothing more than what many of us have been saying for most of a decade.  I am not going to identify him because I am not trying to embarrass him.  (However, I have to say I will not show such restraint if he really has a publication coming out, as he hinted, that claims that his own exciting new research has discovered… well, facts and insights that appeared in the 2006 TobaccoHarmReduction.org FAQ and continue to appear and be updated in our summary report on THR (e.g., Chapter 2 of the 2010 Yearbook, and our forthcoming chapter in the Alan Marlatt tribute book, Harm Reduction 2nd Edition.)

My reason for mentioning this is to express further dismay about the stalled state of THR among the elite or chattering classes.  There has been great innovation in products and progress in uptake of THR, of course, which is much more important.  But the discussion has been pretty much stalled, perhaps waiting for governments to act.  So apparently the only way to liven things is to bring in someone with nothing new to say who just repeats (in a mangled fashion) exactly what many of us have been saying for most of a decade.  Of course, that statement is part self reflection — apparently I do not have enough that is interesting to say that I did not say in 2009 (which may indeed be the last time I introduced a genuinely new important idea).  What more can we say to help move things forward?  Or are we researchers and chatterers basically done, and the world will evolve based on what we have put on the record, with it not much mattering what more we do now?

I actually think that the populist thinking, as an alternative to supplicating to regulators and ANTZ, is important — both as a social science point and a practical suggestion.  But, as I said, that may be a bit too far ahead of the room.  Or I might be wrong.  But my experience says that two or three years from now, someone will be reciting a mangled version of the same points — without citing precedent and thereby claiming it is some purely personal discovery — and the room will be impressed by their insight.

Schedule disruption

Just to let everyone know, our weekly reading will be slightly misnamed this month: We will post, sometime in the next few days, one for the last week plus a few days. The next one after that will be about two weeks later, and we will try to cover the entire time period. We should resume the usual schedule by the end of the month.

In the meantime, I will write a few live-ish blogs from the Society for Research on Nicotine and Tobacco meeting, which is next week in Turkey. I have a feeling it will feel like writing a dispatch from behind enemy lines, but we shall see. They will either be here or at a CASAA forum — I will try to update this post to say which when it is decided.

UPDATE: The posts from and re SRNT will appear here: http://www.facebook.com/topic.php?topic=16723&uid=158188647867

(Don’t do Facebook?  I understand, but it is worth creating an account to be able to read things.  You can “friend” my professional account and get announcements about my writings and only a little other, almost all work traffic.)

Legacy tests waters for making nicotine a controlled drug

[We had a bit more to say about this one than would fit in the Weekly Readings, so are making a separate post of it.  The Weekly Readings should appear later today.]

aThis week, two authors, the first of whom is employed by the tax-funded anti-tobacco extremist organization, American Legacy Foundation, wrote an anti-e-cigarette editorial in the New England Journal of Medicine.  Despite the fears of some THR advocates, no one seems to care much about it.  This is not too surprising since the essay is basically content free, repeating the same old prohibitionist claims with even less substance than is typical.  But we should not overlook the real implications of this:  It has to be interpreted as a policy declaration by Legacy, that they are going to campaign against all low-risk alternatives to smoking, not just smokeless tobacco.

The essay reads like it was written by someone following the instructions in a high-school science class to make a paper sound sciencey, with pointless few hundred word descriptions of what nicotine and e-cigarettes are and do — too short and narrow to be useful (they describe a single e-cigarette technology that has already been better described , failing to recognize the explosion in variations over the last year) and nothing new for anyone interested in the topic.

The only reward for the reader is the unintentional irony of their complaint that the term “e-cigarette” is misleading.  Notice that this complaint about naming is coming from an anti-smoking/tobacco (and now anti-nicotine) propaganda marketing organization called “American Legacy Foundation”.  Jefferson et al. would be rolling in their graves if this were really the American legacy.  Their reason for calling the term misleading is not entirely clear, but it seems to be that these devices work more like other inhalers than they do like real cigarettes.  This is true, but totally missed the point that more consumers find e-cigarettes to be the most appealing mimic of cigarettes, and so they are similar in the one way that counts.  Of course, caring about what consumers actually want and like is not exactly Legacy’s strong suit, so their failure to understand this is not too surprising.

Most of the content is the typical “throw everything against the wall to see what sticks” approach of propagandists.  They make the usual unsupported claims about safety risks.  They point out that e-cigarette rigs can be used for delivering illicit drugs, though their policy proposals about nicotine will do nothing to stop this from happening.  They misconstrue legitimate concerns about quality control and the trivial amount of data that exists (and which does not really support their claim) as actual existence of quality problems which have never arisen.  They repeat some of the dumbest claims about poor nicotine delivery, apparently not realizing that this is one aspect of quality that consumers can detect and compensate for themselves.  Again, the bias of treating nicotine users as complete morons who need to be nannied is clear.

The recommendations in the essay mostly focus on the usual nonsense about “approved” cessation methods and other nicotine products (though, not surprisingly, even as they allude to pharma nicotine products as if they are a satisfying alternative, they do nothing to address to problem that activists like the authors, and the FDA regulators they have blind faith in, are the reason that even the few people who like these products mostly do not know about THR).

But here is the bit that might matter:

For refined nicotine to ever be safely marketed under these standards, regulation must also include strict requirements — no different from those for other consumer drug products — for evidence of safety, consistent specifications, quality control, and functional dose limitations.  Regardless of how regulation of refined nicotine occurs, it must ensure that no existing or future products slip through the cracks.

Though a bit subtle, this is a call from the richest anti-tobacco extremist organization in the world to make nicotine itself a scheduled substance, the only way they could fulfill this goal of asserting control over both existing and not-yet-imagined delivery systems.  In other words, this is not the usual attack on branded manufacturers (“Big Tobacco” et al.), but is aimed more at the artisan vaping community. A regulation of the form they propose might be used to ban all e-cigarettes, of course.  But what it would definitely do would be to criminalize the innovative small-manufacturer and do-it-yourself products that are preferred by many dedicated aficionados and advocates.  Perhaps Legacy has figured out that their prohibitionist agenda is best served by letting cigarette companies and maybe a few new firms take control the e-cigarette market with highly regulated products, with the plan to then eliminate them in ways that a populist movement could not be stopped.

This might be reading too much into a single, mostly cut-and-pasted editorial, but given the authorship and choice of periodicals, it is seems perilous to assume it is a throw-away.  The press was (unusually) wise in not giving this screed any play because it contained no content that was relevant to their readers.  But the public health community (i.e., those of us who support THR) and e-cigarette producers and consumers should not ignore the subtle threat of a ramping up of attacks by the extremists.

Is tobacco control playing Br’er Rabbit in the Aussie briar patch?

by Carl V. Phillips

Those who follow tobacco policy will know that the latest upping of the ante in anti-tobacco regulations is Australia, trying to go one further in its extremism than Canada (though they cannot compete with south Asian countries that lack the rule of law).  They are on the verge of requiring that cigarettes be sold in plain olive drab packages with nothing on them but the plain-text product name (and, of course, offensive pseudo-warning graphics).  The rhetoric is that the plain packaging initiative will reduce smoking and that this is the next step that tobacco control wants to bring to the world.  But what if that is really not true?  What if those who pull the strings behind tobacco control are really trying to lose this one?

There has been much criticism about how this initiative will do nothing to reduce smoking, as any moderately knowledgeable analyst must surely realize, and represents tobacco control going too far.  But this is pretty much true for all of tobacco control’s new initiatives in countries whose policies they already dominate.  There simply is nothing useful left to do other than, of course, pursuing harm reduction.  Whether it is banning smoking in movies or in public parks, the proposed new regulations have no realistic prospect of affecting use prevalence.  Indeed, the primary effects of new initiatives are quite negative for the anti-tobacco extremists:  They increase the appeal of low-risk nicotine products, and cause casual observers to start to recognize that tobacco control people have long-since ceased to be public health advocates and are now effectively religious zealots.  The former of these is actually a bigger threat, because once a society discovers and understands the benefits of THR and low-risk nicotine, tobacco control will (a) lose any chance of forcing complete abstinence, because people will recognize there is no justification for that, and (b) lose their gravy train.

So, what has sustained tobacco control up to this point?  They have managed to trick people into thinking that they, by far the richest and most dominant faction in discourse about tobacco, are scrappy underdogs desperately trying to get their voices heard, and that they are not failing in their promises because people like to use tobacco, but because of some powerful boogiemen.  That fiction becomes rather difficult to sustain when they win every battle get everything they demand, though.  And the fiction they are really doing something beneficial is hard to sustain when they get everything they demand and it turns out to accomplish nothing.  But what really keeps the sympathy, faith, and money flowing is losing.

Enter plain packaging.

Plain packaging takes away trademark rights and brand equity.  Honest observers realize that this will not diminish the appeal of cigarettes as a category, and will probably facilitate increased sales of cheaper and possibly unhealthier black market products.  But the dominant cigarette companies in the Australian market, particularly BAT, know that the threat to their individual profits is substantial because they depend on brand equity and the legal market.  This is particularly true if the arms race among anti-tobacco countries causes others to adopt plain packaging.  They also know that international treaties that are far more respected and important than the FCTC protect their trademarks (see here for a discussion).  They stand a good chance of getting this overturned.  Did tobacco control not realize this, or is it that they were they always playing Br’er Rabbit (who begged to not be thrown in the briar patch, the one place he knew he could escape from):  “You evil tobacco companies better not throw us in the briar patch or mount a legal challenge against our lily white public health initiatives!”

If the plain packaging were implemented without incident and the inevitable increase in black market sales and lack of decrease in use prevalence occurred, it would be one more step into the cul-de-sac of irrelevance for tobacco control.  Oh, but if the industry can be tempted into fighting this, and better still if they win, jackpot!  “Big tobacco wins again!”  “Important public health measure prohibited on a technicality.”  “We would have eliminated smoking in Australia with this, but Big Tobacco just has too much influence.”  That is good for at least five more years of full employment for anti-tobacco extremists.

No doubt that many of the advocates and pundits involved in this really believe in the initiative.  I think it is safe to say that most people working on tobacco control are idealists who are no more aware they are being manipulated than are Tea Party members aware that they are doing the bidding of the Koch brothers.  Perhaps even Simon Chapman in all his clueless lunacy actually believes what he is saying.  But it is difficult to not wonder if there are some smart people behind the scenes who have been running this as a long con from the start.  Anti-tobacco did not get wealthy and powerful by being as dumb as their propaganda is, after all.  It certainly seems like everyone is following a long con script perfectly.

I suppose that it is possible that no one was really playing a game from the start.  We will never know, however, because no doubt that one of these schemers will claim in their memoirs that it was their plan all along, whether or not it was.

TobaccoHarmReduction.org’s comments on UK NICE’s THR guidance scoping draft

posted by Carl V Phillips

The UK National Institute for Health and Clinical Excellence (NICE) has an ongoing process with regard to tobacco policy, and we are a registered stakeholder.  Recently they produced a scoping document on the part that is most relevant to us, entitled “Smoking harm reduction” or “Tobacco – harm-reduction approaches to smoking”.  Following our usual practice of publishing our submissions, we are posting here our responses.

Reading the whole thing requires a bit of effort because the required format, for what is a sort of a peer-review type exercise, involved commenting section by section.  So to understand our comments, which we have attached in full (pdf), it is necessary to cross-read with the draft scoping document.  So, those are linked from this paragraph for those interested in reading our entire message.

For those interested in a simpler reading experience, what appears below is a stand-alone cut-and-past of most of our key points of general interest, organized for reading rather than according to the comment form:

We identified three major concerns with the draft scoping document: a strong emphasis on abstinence in what is supposed to be a THR approach (though not an apparent confusion of the two); an emphasis on simply reducing the number of cigarettes smoked in a day over other harm reduction approaches; and the explicit exclusion of consideration of the low-risk smokeless tobacco products as a substitute for smoking.

Our final point captured some of this with:

As a final note, the emphasis on abstinence and the limited mentions of product substitution leaves us concerned that political forces are on the verge of turning this into an anti-harm-reduction project.  While that will pose no great threat to THR (the anti-THR market is already saturated), it could damage NICE’s credibility.  More important, it would turn this rare opportunity to intelligently examine the potential for THR into yet another ineffective generic anti-nicotine effort.

Part of the problem was a failure to even define what harm reduction means in this case, and we offered the definition:

THR is properly defined as an approach to reducing the harms from smoking that does not include becoming abstinent from nicotine use.  The term is used to refer to either the individual’s behaviour change or policies that promote such change.  At the core of this is substitution of low-risk nicotine products for cigarettes.  These products include modern Western smokeless tobacco products (ST; e.g., snus), which have been shown to cause about 1/100th the health risk of smoking, as well as electronic cigarettes (e-cigarettes) and pharmaceutical nicotine products, which are generally believed to pose about the same risk as ST though this requires extrapolating from the evidence about ST because there is no direct evidence.

Two other changes that are sometime included in and sometimes excluded from THR are reductions in the quantity smoked but with no use of substitute products and changes to cigarettes that create incremental reductions in the hazards.  We do not tend to include either of those in the term, but recognize that they are not clearly excluded.  The latter of these is explicitly excluded in the present context … while the former seems to be implicitly included in some of what is mentioned in the document.

What cannot be legitimately included under the term THR are efforts to become nicotine abstinent or to promote nicotine abstinence.  Such efforts are not THR even if they include product substitution as a method of weaning off of cigarettes so long as the goal is for near-term cessation of those products too.  Harm reduction is a term of art that refers to allowing continuation of some core behaviour (notably including drug consumption), but changing the details of the consumption to reduce the health impact.  It is important to distinguish this from nicotine abstinence because some political opponents of THR, who embrace an abstinence-only approach, have attempted to co-opt the term.  (Sometimes this tactic involves pretending the term has its natural language meaning and pointing out that abstinence reduces harm, so it must be harm reduction.  Other times it results from confusion about use of substitute products for weaning toward abstinence, incorrectly equating short-term low-risk product use with THR.)

In this context, we make the following point, which we think is fairly critical:

No judgment about the relative merits of abstinence versus THR is necessary in order to recognize that they are distinct, and that the present scope is supposed to be about the latter.

Though it does not relate to anything in NICE’s document, we know the political climate.  Somehow many of the fanatical opponents of THR are incapable of clear thinking to the point that they cannot distinguish “I really hate this idea” from “this idea does not really exist”.

Later, re the section about what questions need to be answered, we added this observation on the point about the creeping abstinence-only theme:

There is more emphasis on nicotine abstinence in the “key questions” than there is on harm reduction.  This is both odd and inappropriate.  It is inappropriate because this document is supposed to be about harm reduction, and yet the “key questions” are mostly not about harm reduction.  It is odd because there are far more important open questions about THR than there are about abstinence promotion, which consumes enormous research resources.  So why does the list about what we might want to know about promoting THR suggest that we squander the opportunity by repeating existing and over-supported research on abstinence promotion?

On the emphasis upon merely cutting back quantity smoked, we wrote:

It should be noted that reducing the quantity someone smokes (not to zero), as is emphasized in this document, particularly in the “key questions”, is not a particularly good harm reduction strategy.  Occasional smoking is considerably lower risk than daily smoking, but just reducing the number of cigarettes consumed while still smoking daily offers less benefit than is widely believed.

Speaking very roughly, the reduction in cancer risk drops about linearly with cigarette quantity reduction, but the cardiovascular disease risk is close to plateauing for fairly few cigarettes per day so may not change much.  Someone with non-cancer lung disease might also see only limited benefit from continuing to smoke, but reducing quantity.  It is worth noting that many avid anti-smoking activists are currently claiming that even very small quantities of smoke cause harms of the same order of magnitude as typical smoking behavior.  We are not endorsing such claims, but note this to point out that mere reduction in quantity smoked is not an approach that is recommended by either those who actively advocate harm reduction or those who promote abstinence and prohibitionist approaches.

Yes, reduction in quantity does reduce harm.  And it is important to note that partial substitution of low-risk products while continuing to smoke some is a very common step on the way to adopting THR through complete substitution.  But emphasizing simply “cutting back” over more beneficial harm reduction options (i.e., full product substitution), as this document often seems to do, seems unwise and difficult to justify.

On the exclusion of smokeless tobacco substitution from consideration as part of a harm reduction strategy, we wrote:

The exclusion of the substitution of Western smokeless tobacco products (ST) for smoking is a fatal flaw in this scoping.  While we understand that those ST products that are most promising for THR are banned in the EU (outside of Sweden), this does not excuse the failure of a scientific or public health analysis to even consider what they could contribute to THR.

Some policy processes ask the question “how can we best implement the mandated policies of the government (or of the super-government in Brussels)?”  While we are not expert on the legalities of the present process (our relevant expertise is in various social and natural sciences and ethics) it is not our impression that this describes the present process.  A serious study of THR in the EU context should include inquiries that might call into question the EU ban of snus, rather that being restricted to the assumption that the ban is wise.

Though e-cigarettes are gaining fast, the majority of successful THR in the world consists of smokers or would-be smokers substituting ST.  Moreover, the evidence that THR is a promising intervention from an individual (and thus public health) perspective is based on the evidence about ST.  Even the pharmaceutical industry has argued that their products should be accepted as low-risk alternatives to smoking based not on evidence about long-term usage of those products, of which there is precious little, but based on the evidence about ST.

ST remains the most promising alternative for many smokers, and even if alternative devices prove more popular with most users, there is no reason to not allow those who prefer ST to use it, the one product for which there is actually evidence of the low-risk.

The document listed something that might be seen as a research agenda in the form of a list of “key questions”.  We found that these really missed the point about what the key relevant questions really are (you can see the proposed questions and our specific critiques of them in the links above, and I wrote a more in-depth analysis of a couple of them at EP-ology).  We proposed that the real key unanswered questions about a policy of promoting THR are:

What are the main barriers that stand between people who are good candidates for adopting THR and actual adoption?  How much is just misinformation?

Are there effective strategies for overcoming those barriers?  Many smokers try low-risk alternatives and decide to not switch; are there ways to make them more likely to complete the switch?  Many smokers insist that they prefer smoking and will not switch; are there strategies for helping them better think “do I like it that much more that it is worth the health costs”?

How can the use of smoke-free nicotine products by smokers in non-smoking situations be leveraged into switching entirely to the low-risk alternative?

A couple of specific criticisms of the questions that are not picked up on in that EP-ology post:  A couple of questions focused on how, basically, to pick winners — to figure out which products are most liked.  But there is no reason to do this other than curiosity:

Implicit … is the suggestion that it ever makes sense to limit someone to one type of substitute product.  We are aware of no basis for recommending this, and substitution studies and interventions that restrict choices to a particular product appear to be either commercial efforts to promote a particular product (rather than to research THR more generally) or intended to fail.  Similarly, the implicit suggestion that particular combinations should be explored and ordained as best by policy makers is misguided.  People have heterogeneous tastes and low-risk nicotine products are a very heterogeneous collection.  The market is large enough to support many low-risk options.

Educated consumers have a choice of products and will like some better than others, preferences which will differ across the population.  It simply makes no sense to not always facilitate individual choice of what works best for each individual by offering all the choices.  Indeed, any attempt to do otherwise can only be interpreted as an effort to make THR appear to be less promising than it is or to promote one company’s or industry’s profits over its competitors.

Regarding the question that asked “Does long-term use of pharmacotherapies or ‘nicotine containing products’ to reduce smoking have any ill-effects on health?” we wrote:

This is certainly a legitimate question in theory, but it should be realized that no better answers to it are going to be learned any time soon.  We know most of what is useful to know about ST and are unlikely to ever observe the long-term effects of other current products (because few people will use them close to exclusively for a long time before they are replaced with new technologies).  Thus, our current knowledge about the long-term effects of ST will remain our source of knowledge about this question for the foreseeable future.

The first part of the document included the usual boilerplate about how many people smoking kills and such.  We ignored most of that (it did not really matter whether it was sound science or not because that material is just window-dressing), except for the claims about how many smokers want to and try to quit:

In the context of harm reduction, it is important to understand that “wanting” to quit and “tried” to quit often do not mean what a casual reader might interpret.  Simple self-identification into those categories can mean any number of things, and is thus fairly meaningless.  In particular, the naïve interpretation of preferences is something like, “I want to be abstinent, with all that implies, but somehow cannot do it”.  But what is often really present is a second-order preference (i.e., a preference about having different preferences) like, “I want to be just as happy as a non-smoker as I am as a smoker” or equivalently “I want everything to be unchanged in my life except that I no longer smoke”.  These second order desires are common and are very different from the option that is actually available.  In some sense they represent cases where the smoker really does not want to quit (all things considered), and thus fails to do so (because, despite the self-identification as someone trying to quit, he really prefers a world in which he smokes to one in which he is abstinent).

In that context, many quit attempts can be seen as wishful thinking (spurred on by many of the claims about why people smoke) about abstinence being preferred once it is achieved, which results in disappointment.  The “attempts” might be better seen as experiments rather than “failures”.  Few people are able to articulate that their preferences are really the second-order version, and many have been denied the vocabulary that is required to say, “I successfully quit and was definitely an ex-smoker for a while, but then made the conscious decision that I like life with nicotine better than life without, even considering the costs”.

To the extent that want-to-be-quitters are expressing second-order preferences for wanting to not smoke but wanting even more to be as happy as they are when experiencing the benefits of smoking (primarily self-administration of nicotine), harm reduction is a particularly valuable approach.  Such individuals are practically begging for THR.  Thus, while the other standard boilerplate about smoking in this section is relatively unimportant, understanding this phenomenon and correcting the naïve view is critical in the context of THR.  Some people who assert they would like to be tobacco/nicotine abstinent are really indicating a preference for the benefits of nicotine without the costs of smoking.  This is a key argument in favour of supporting THR rather than an abstinence-only policy.

We questioned why specific subsets of smokers were identified as the target population for harm-reduction interventions:

Even those who are not actively considering quitting or reducing their risks right now should be considered part of the ultimate target group, who can be educated about THR and perhaps adopt it someday.

That covers most of what casual readers of the topic will probably want to read.  Those with a deeper interest in the topic or in the NICE procedure will want to read the full document.

FDA concedes it will regulate e-cigarettes as tobacco products; the devil awaits

by Carl V Phillips

As those of you who read this blog presumably already know, the US FDA announced that it had decided to treat electronic cigarettes as tobacco products for regulatory purposes, which effectively legalizes them, contrary to FDA’s original plan.  Well, “decided” is not really the right word, given that a court ruling already told them they would have to do that.  This is basically good, though not really good news (even the timing was predestined – yesterday was the day by which FDA had to commit to the sensible course of not appealing the court ruling to the US Supreme Court).  But I have to say that I have not seen anything in the details or anyone else’s analysis that gives any indication of whether this is really good or not.  The devil is in the details, and we have precious few of those.

Ironically, this means that the three most newsworthy acts of the FDA’s new tobacco regulators have been to:

  • ban flavored cigarettes that really did not exist (as mandated by the enabling legislation),
  • declare certain smokeless tobacco products to not be tobacco products (apparently to delay having to deal with making some of the tougher rules required by the legislation)
  • and, now, to declare certain non-tobacco products to be tobacco products (as mandated by a court).

If you step back and do not take the whole thing to seriously, it is actually pretty funny.

FDA’s statement was widely reported (here is the AP story and see my Unhealthful News post for others) and commented on (Godshall, Rodu, CASAA, Michael Siegel).  It suggests, as Rodu also notes, that there is the possibility of sensible quality-control based regulation, which is better than no regulation at all.  Rodu also suggests that this invites pharma companies to remove medicinal labeling and market their nicotine products in the same niche as e-cigarettes (that is as regularly self-administered recreational or “lifestyle” drugs), though Godshall argues that it spells doom for their products.  An in-between version might be that licensees or spin-off companies could market versions of those products if the pharma companies are simply not able to function in the fast moving consumer goods market.

But FDA could still seriously mess with the selling of e-cigarettes if that is what they want.  I did not see any evidence this week of pro-THR thinking or a plan to be any more favorable toward e-cigarettes than is absolutely required by the court ruling.  This means, for example, that any product that is not almost exactly the same as something that was on the market before February 2007 might be required to go through new product applications which would be largely prohibitive.  This could easily include most of the current high-end and creative products, as well as most refill liquid (aka “juice”, “e-liquid”) .

Like I said, the devil is in the details, some of which we do not even have hints about yet.

It seems almost certain that FDA will cling to its nutty anti-scientific position that marketing statements that make even the obviously accurate claim that e-cigarettes are a way to not smoke, at least at the same time you are using the e-cigarette, will be prohibited.  FDA’s signals to date suggest that they would declare even that statement to be an unproven therapeutic claim that needs to be proven with randomized trials.  FDA has never been known for having the firmest possible grasp of the obvious, let alone an understanding of the inappropriateness of randomized trials in many cases.  This probably will not matter much, since manufacturers can just avoid saying anything at all about the product, leaving that to user groups, social networks, blogs, and other sources of information.

But the FDA could probably require labeling that says that the devices are not a safe alternative, have particular risks (even if there is no evidence of such risks, as with the labeling on smokeless tobacco), are not useful for quitting smoking, or other anti-THR statements.  Again, it probably would not matter much, but it might encourage smokers who pick up a disposable e-cigarette to get them through the day to keep smoking.  So far, only one anti-tobacco extremist group, Campaign for Tobacco-Free Kids, has spoken up against the FDA announcement, since their goal is to make sure that smokers keep smoking unless they become completely abstinent (as I have discussed at length, the only lever the prohibitionists have is making sure that nicotine use remains deadly).  CTFK condemned FDA for embracing reality rather than try to take the case to the Supreme Court.

Finally, it seems likely that this paves the way for unified treatment of products, which has some bad implications for e-cigarette supporters.  The piecemeal regulation by local governments of e-cigarettes, both the reasonable and the anti-THR bits, could be replaced by template-based legislation that is adopted almost everywhere, restricting e-cigarette and nicotine solution sales to the same customers, sales venues, delivery methods, etc. that are allowed for cigarettes, as well as similar taxation.  This could put a serious crimp in the current distribution network and reduce many of the advantages of e-cigarettes.  And the CTFK-types will probably get rules that favor cigarettes over e-cigarettes inserted in many jurisdictions.

Of course, such rules might be a bit difficult to enforce for anything other than packaged disposables, since the self-fillable products are just electrical devices.  Regulating “paraphernalia” is extremely difficult (witness the thriving market for legals devices to smoke the largely illegal cannabis).  The battleground then would become nicotine solutions which opens up interesting possibilities since to make this enforceable.  Probably nicotine itself — a cheap, easily available chemical — would have to be made a controlled substance, which there are no provisions for.  So far.

Some interesting things are in store.  This week’s event is largely just a reminder of that fact.

New study shows that smokers are misled by erroneous information

by Carl V. Phillips

Readers interested in the topic may have already seen the headlines (dutifully reprinted from the press release by lazy news outlets), “Smokers believe ‘silver’, ‘gold’ and ‘slim’ cigarettes are less harmful”.  Of course, that belief seems quite likely to be true, and so is not what I am referring to in the headline here.  What the study shows that smokers are clearly intentionally misled about is something much more important that the authors buried (it did not appear in the abstract and I am shocked that some impulse toward honest reporting, perhaps left over from their education or previous careers, caused them to mention it in the press release):

Smokers in the study also revealed false beliefs that … nicotine is responsible for most of the cancer caused by cigarettes.

The apparent goal of this study was to provide an excuse for further regulation of packaging because it sends signals about which brands are slightly less hazardous.  The authors practically declare that they were setting out to do this.

It is true that the differences in risks among existing cigarettes are small enough that they have not been measured.  In part this is for lack of trying, since an Official Myth of anti-tobacco is that all cigarettes pose exactly the same risk, which is obvious absurd.  This is so obviously absurd that I would be amazed that they would make such a ridiculous claim, let alone get away with it, if I were not aware of what other claims they make and get away with.  Of course different cigarettes pose different risks – the exposures differ a bit and so the outcomes are going to differ a bit.  Cigarettes differ in their concentrations of the toxins that activists/researchers (sometimes the same ones who like to insist there is no difference) present as sources of the harm, after all.  Indeed, the difference between the risks across major cigarette brands is undoubtedly bigger than the difference between using smokeless tobacco or e-cigarettes and being nicotine abstinent, a difference that the anti-tobacco extremists pretend is huge.

As for which brands are slightly more or less harmful, we do not know for certain, but the consumers’ guesses – that low tar and filters are better – seem like where the smart money should be.  Consider the fact that some jurisdictions limit the tar content, and thus the regulators seem to agree.  It is not clear from what was reported exactly how the survey questions about comparative risk were asked.  I suspect the phrasing implied “is there any difference in risk whatsoever” rather than “is there a big enough difference that smoking the less harmful ones is enough better for you that you should not worry about the risks if you smoke them”.  Of course, the authors are playing the activist role – the current fashion in activism being all about the latest doomed effort to discourage smoking through gimmicks, taking away the pretty colors on the package that are obviously the reason that people smoke.  The authors are implying that the survey respondents were answering the second of those comparison statements, whereas I suspect they believed themselves to be answering the first of them.  That is, they were giving the undoubtedly correct answer (that there are differences) and the probably correct answer (that the differences favor the “light” brands) rather than the Official Propaganda answer that there is absolutely no difference.

For shame!  We must immediately sack the Minister of Truth and investigate what has gone wrong.

But the really dangerous misinformation this study reminded us of (though we already knew it, since dozens of studies including our own have shown it) is that most smokers think that the nicotine is a, or even the, major cause of health risk from smoking.  This, of course, is a great victory for the Ministry of Truth-style anti-tobacco extremists, since it helps make sure that smokers keep dying until they quit, minimizing the chance that they save their lives by switching to a low-risk alternative.  Smokers have been intentionally convinced that “tobacco” and nicotine are the sources of their risk, not smoking itself, and this convinces them that they might as well smoke rather than switch products.  Put another way, the lies about all nicotine products posing the same risks are not limited to the relatively harmless lie that all cigarettes are exactly the same (even though they undoubtedly differ in risk by several percent, perhaps even 10%), but include the immensely harmful lie that low-risk nicotine products pose the same risk as smoking (even though this is wrong by about 99%).

So, to slightly rewrite part of the last paragraph of their press release and conclusions of their abstract, respectively:

Dr. ——, one of the researchers on the study, says that the study provides evidence for further regulation. “The findings highlight the deceptive potential of information targeted primarily at young people who might be good candidates for saving their lives by product switching.”

Despite current prohibitions on government-sponsored misleading statements, smokers in western countries continue to falsely believe that no nicotine products are less harmful than others. These beliefs are associated with descriptive words and elements of package design that have yet to be prohibited.

See if you can guess which of those words I added without peeking at the original.  It is fewer than you might think.

greetings from Vapefest Philadelphia

by Carl V Phillips

This is not a live-blogging kind of a blog, but I thought I would do a few over the next week or two.  Right now I am at Vapefest (the e-cigarette aficionados gathering) — quite an interesting experience.  This is not the scientific, public health, or even harm reduction side of the low-risk nicotine issue.  Not, mind you, that there is no interest in those.  This place is thick with knowledge about all of those topics (and with sweet smelling vapor).

But there is something totally different about this compared even to harm reduction meetings.  I am intrigued by the hobbyist aspect of the whole enterprise.  There is an amazing collection of variant devices for vaping and an amazing knowledge base about how to make them and the “juice”.   I still fear for the current smokers who have never heard of vaping, or have been convinced by disinformation from the FDA and others that it is not a sensible alternative to smoking.  I still worry about quality control of mass-produced e-cigarettes and, honestly, people with inadequate crafting skill messing around with nicotine solutions to make their own e-cigarette liquid.  (I say this as someone whose handiwork skills are such that I very proud of myself for successfully replacing his burned out car headlight on the way here.)

But I am increasingly not worried about the fear that sometimes exists that dedicated vapers will return to smoking when bans or restrictions are imposed.  Further restrictions, bans, or lies regarding e-cigarettes will undoubtedly kill some would-be switchers, who might have picked up a simple e-cigarette product at a mall kiosk, but will instead die from smoking.  But no one is going to stop the people that I have met here.  Banning this would be far more difficult than banning cannabis smoking, and we know how well that works.

Jonathan Foulds — who I had not realized had abandoned the swamps of Jersey for the greener pastures of rural PA — was here collecting survey data, which I would venture to say will show, once again, that e-cigarettes are an effective method of stopping smoking.  (Can we please stop differentiating between “smoking cessation” and “substituting for smoking”.  There is no difference in that distinction.)  I find it intriguing that Pennsylvania could emerge as the center of center of such research.

I find it quite gratifying to meet people who know me well, from our research and writing on THR, but who I normally never have a chance to meet.  What we do can get pretty lonely (post comments!!!), and even though we know you are out there, it means a lot to have a few conversations.

That’s it for my first venture in live blogging.  I will continue it tomorrow.