Monthly Archives: September 2015

From smoking to dual to switching (Snus or E-cig), a story of a pretty normal human behavior!

Thank you Kristin Knoll-Marsh for sharing this on Facebook, since it is in the public domain already I feel comfortable sharing it with you, whether you are in Turkey, In Cyprus, In Northern Cyprus, in the USA, in Sweden or perhaps Azerbaidzjan:

My 66 year old, smoking aunt has watched nearly my entire family switch from smoking to vaping over the past 6 years. She never showed any interest – “too much fuss” she said, so we never pushed it. We even set up a smoking area, on our screen porch, for her when she moved in with us a few weeks ago.

A couple of weeks ago, we were at Walmart and I casually mentioned that a disposable cigalike being sold was the most realistic I’d ever tried and, to my surprise, she bought one! A week or so (and 3 disposable ecigs) later, she mentioned she’d like it if it could be recharged and refilled. So I picked up a rechargeable cigalike, with extra cartos, for her when I was in Walgreens.

Yesterday, my husband and I stopped in a vape shop for supplies and she came in with us. She is now the proud owner of a new, shiny, red mod (100% her idea.)

At the store, she told me, “I’m finding that I’m using it (the cigalike) more often then smoking and I’m really enjoying it. I’m only smoking in the morning. So, I may as well get something better.”

This story, folks, is a perfect example of why we need to keep fighting for diversity in the marketplace. Without that first cigalike and unbiased guidance, in a safe, comfortable and reassuring environment, she was unlikely to walk into a vape shop. This can be extremely important for a smoker’s journey from smoking to vaping. (On a side note, this shop only had 2 straight tobacco flavors. Shop owners would be smart to have more than that for smokers.)

It also shows a classic case of a typical “dual user” that the ANTZ are wringing their hands over. Most dual users just haven’t finished their journey. To do so, they need truthful information and gentle guidance, not pressure to jump in over their head with advanced devices and low nicotine levels or to quit smoking right away.

And it makes an important point that many “dual users” are smokers who had ZERO interest in quitting, yet they are now cutting down their smoking and likely on a path to quit that they wouldn’t have been on with only NRT as an option.

This is what CASAA is all about – getting out truthful information about ALL low-risk alternatives!

”Enjoying reading inside with her first ecig - a much-maligned "cigalike." But it got her started!”
”Upgrading just a couple of weeks later - without any pressure. (Side Note: Unfortunately, this shop only had 2 straight tobacco flavors. It would be nice for smokers to have more options in the beginning.)”

Dual use (snus or e-cig) isn’t bad, it’s good. Possibly even really really good

Friday, September 25, 2015

 An important new study led by Dr. Christopher Russell of theCentre for Drug Misuse Research in Glasgow and presented recently at the 2015 Tobacco Science Research Conference reveals that contrary to the claims of many anti-tobacco advocates, dual use (of e-cigarettes and tobacco cigarettes) is not a negative consequence of e-cigarette use, but a positive outcome that could well stand on a pathway to eventual smoking cessation.

(Russell C, McKeganey N, Hamilton-Barclay T. An online survey of 5,000 vapers’ perceptions and experiences of using electronic cigarettes as an aid to smoking cessation. Glasgow, Scotland UK: Centre for Drug Misuse Research. Presented at the Tobacco Science Research Conference, September 22, 2015.)

In the study, a worldwide internet survey was conducted and was available in seven languages. It was advertised on social media and through e-cigarette fora. The recruitment materials invited the participation of all adults who had ever used an electronic cigarette, even a puff. Importantly, it was not restricted to experienced vapers who had success quitting smoking. There were 7,326 respondents.

The most important study findings were as follows:

  • Of the dual users, 64% reported having reduced their cigarette consumption;
  • Of the dual users, 56% had cut their cigarette consumption by 50% or more;
  • Of the dual users, 81% reported having quit smoking for a period of at least one week;
  • Of the dual users, 70% reported the intention to quit smoking within six months;
  • Of the dual users, 88% reported that they planned to cut their cigarette consumption by at least half in the next six months;
  • Of the dual users, 63% predicted that they would quit smoking completely within six months, and another 27% predicted that they would cut their cigarette consumption within six months.

The Rest of the Story

Although this sample is of course not representative of the population, it does reveal important information about the attitudes and behavior of a large sample of dual users. The recruitment methods likely attracted a sample that had a disproportionately positive experience with electronic cigarettes, so these results should not be generalized to the overall population. However, within this subset of the population, it is clear that there are a substantial number of dual users for whom electronic cigarettes are having substantial positive consequences, even though they have not quit smoking completely.

This is critical information because most tobacco control advocates and groups have argued that quitting smoking is the only potential benefit of electronic cigarettes and that dual use is a negative consequence. These study results call those assumptions into question.

First, it is clear that a large percentage of the dual users had significantly cut down on the amount they smoked. This, in itself, confers substantial health benefits, especially in terms of respiratory symptoms and progression of respiratory disease. It also reduces smoking addiction and makes it easier for these smokers to quit in the future.

Second, it is clear that electronic cigarettes are being used as a part of an overall plan to quit smoking and that dual users largely were committed to eventually quit smoking completely. Even more importantly, nearly two-thirds of the dual users had positive self-efficacy for quitting, predicting that they would be smoke-free in six months time.

These results also call into question the claims of many anti-tobacco advocates that use of electronic cigarettes is inhibiting smoking cessation by removing the intention or desire to quit. It appears that among at least a subset of dual users, the e-cigarettes are being used as part of a smoking cessation plan and the intention to quit remains. In fact, the level of self-efficacy of these dual users is much higher than we observe in general smokers in the population.

This study certainly points the need for a similar survey to be conducted among a representative sample of smokers who try electronic cigarettes but fail to quit (i.e., a large, representative sample of dual users). However, the preliminary data from this study suggest that the use of e-cigarettes by adult smokers should be viewed as an integral part of an overall plan to quit smoking and improve one’s health. And vaping appears to be helping smokers achieve both.

Lung Cancer Science International reluctantly follow the crowd and advocate sensible policy on Snus and E-cig

After the 16th conference by IASLC (International Association for the Study on Lung Cancer, September 2015 in Boulder, Colorado) I give you some excerpts from the Tobacco Policy Document. I am quite certain that the first excerpt below very succinctly describes and also quantifies the immediate and urgent need to realign world tobacco policy on e-cigarettes and food grade smokeless products simultaneously.

Not doing so and focusing only on e-cigarettes will undoubtedly be suboptimal to addressing the issue in LMIC (Low and Middle Income Countries) who represent both the growth of smoking, and the rapid growth of Lung Cancer incidence.

“Worldwide, lung cancer is the leading cause of cancer death. While the epidemic of cigarette induced lung cancers is now beginning to subside (particularly in men) in many high income countries as cigarette consumption has fallen, worldwide lung cancer deaths are projected to increase in the coming decades as smoking rates increase in low and middle income countries (1, 2). The projected global epidemic of cigarette caused lung cancers is entirely preventable.”

“Adopt policy measures that recognize the probable differences in the lung cancer risk of alternative nicotine delivery products. Adopting policies that favor less dangerous (non- combustible) forms of nicotine delivery over cigarettes would provide a powerful incentive for people who smoke to move away from cigarettes which in turn would have a profound impact on global lung cancer rates in the coming decades.”

“Join together to forcefully implement the World Health Organization’s Framework Convention on Tobacco Control which has among its key provisions increasing cigarette prices via taxation (to at least 70% of the retail price), prohibiting the sale of cigarettes to minors (less than 21 years of age) , enacting and enforcing comprehensive cigarette marketing policies, eliminating tobacco use in public locations, mandating graphic warnings labels on cigarette containers, implementing public education campaigns to discourage the use of cigarettes, and providing tobacco cessation support.”

Media exchange between myself and Swedish Public Health August 21st – Sept 3rd 2015

Dear Reader, finally a reply from Swedish Public Health on my snus Op-Ed article in Sweden’s largest daily. My response to their response is on top, the best known tobacco researcher in Sweden who was kind enough to reply is in the middle, and finally on the end is my initial article from august that really started the nationwide debate in Sweden. What do you think?

Atakan Befrits: Snus is not a cure, but one of the best cigarette alternatives available – Published: September 2, 2015

http://asikt.dn.se/asikt/debatt/snus-ar-inte-ett-allvarligt-folkhalsoproblem/snus-ar-inte-ett-botemedel-men-ett-av-de-basta-cigarettalternativen-som-finns/

If the Swedish Public Health Agency and the National Board of Public Health both advise the FDA not to allow removal of the cancer warning on Swedish snus, even though it was done in Sweden already 2001, that can hardly be considered to be proper, honest or objective, can it?

If India, referring to Sweden and WHO, creates several million new smokers by banning all types of snus, have they then really understood the situation in Sweden with regards to snus and harms from snus?

Professor Gilljam, thanks for the important and illuminating answers to my opinion article, the answer is very much appreciated and does you honor!

As I see it You do not refute one single critical point in my article, and only confirm what I wanted to highlight, that snus is not a serious public health problem in Sweden, and has never been one.

You mention snus in terms that in the current form, has been around for only 16-17 years and that this is not sufficient to rule out any risks associated with snus. This is not true!

Modern pouch snus with a tenfold higher levels of tobacco-specific nitrosamines, compared with current snus, made it’s entry in the Swedish offices around 1980. So we have quite enough ex-smokers (and exclusive snus users) who have used snus for far longer than 35 years, with no measurable severe damage, more than sufficient to rule out serious adverse health effects. The value in terms of public health and individual health benefits, for Sweden as a country for the individuals, cannot be distinguished from if they quit entirely or never began in the first place (always the best option, of course). Furthermore snus in general, as it is produced and used in Sweden, has not given rise to measurable severe adverse health effects in over 100 years. The Swedish Medical Journal magazine’s paper archives (1904-1995) for example, do not even have the world “snus” indexed, but of course it has hundreds of articles on the harmful effects of smoking.

You mention in your reply that Sweden cannot advocate a harmful product. I agree with you completely. Sweden should not advocate snus internationally in any other respect than that it has played an important role in the Swedish smoking, that is lower than any other EU country, without relevant measurable serious injury. So just completely objectively state established facts in a relevant context, basically just tell the truth, and then let the other countries / people make their own health calculations.

I hope that snus can play an important role in the world as a damage-minimizing tobacco product, but without giving rise to large groups snus users who would otherwise never have used tobacco. If it should prove unavoidable that there are young people internationally who start using snus anyway, one may assume that many of them would otherwise have started to smoke, so even then, snus is distinctly positive to public health. Not so good for Tobacco End Game of course, but infinitely better than if they were to start smoking, right?

You mention in your reply that because of aesthetic and cultural reasons snus has no place outside Sweden (what about Norway, USA, Canada?).

Are over 1 billion smokers practitioners of an aesthetics culture? Moreover also, without foreign influences?

300 million people worldwide are using extremely dangerous forms of smokeless formulations(very very dangerous snus, simply put), in their case it is definitely a question of a local cultural expression, compared with Sweden’s about 1 million snus users.

Therefore I simply cannot see any relevance in the comments about the aesthetics and culture. Women do not like to use snus because it is it’s ugly, true. Women might think it was worth it anyway, if they knew that snus is almost just as good as to stop completely with tobacco/nicotine? Accurate information in a relevant context certainly makes my decisions easier to make, do you agree?

Have we not reason to, even a responsibility to, be open with the information that the way we produce our snus in little Sweden, renders the product virtually harmless? That could hardly be considered advocating snus, or could it?

Finally: Well, Sweden does torpedo snus internationally, as much as we can, and all the time. Both actively and passively. Actively through international letters and studies that are taken completely out of the relevant context, and that definitely does not fit other nation’s contexts where hundreds of thousands die each year of smoking and poorly manufactured smokeless tobacco. Passively we torpedo snus internationally through not ever correcting completely erroneous and often malicious conclusions drawn from “Swedish quality research”. This erroneous conclusions, citing Swedish science, then start a new life as “scientific facts from Sweden”, since no one objects.

India has, with main reference to Sweden and WHO, totally banned smokeless tobacco affecting 200 million users! Instead of introducing quality standards equivalent to the Swedish ones, or for that matter the standards suggested by the WHO in it’s Technical Report 955, India blanket banned smokeless instead.

The total ban in India of course makes improvement, taxation and quality control totally impossible. What is infinitely worse, the tax losses from the now banned smokeless tobacco in India is replaced by increased sales of cigarettes, through tax cuts on combustible tobacco.

Professor Hans Gilljam: The cigarette is lethal – but snus is not the cure! – Published: September 1, 2015

The headline sums up my response to Atakan Befrits post “Snus is not a serious public health problem” in which he argues that the Swedish authorities back-stab snus without justification and that this puts obstacles in the way of snus’ deserved global sales opportunities.

Befrits is quite right regarding combustible tobacco, read “the cigarette”, the cigarette is the “Number 1” that has killed more people than all wars and epidemics combined the past 100 years, and the situation is only getting worse.

However, a full 50-year follow-up of chronic smokers was required to understand the extent of the catastrophe. Modern Swedish snus has only been around for 16-17 years, so it will be some time before we know everything about the harm from snus.

I share Befrits view that snus must be far less harmful than cigarettes, but suggesting that Swedish authorities should actively advocate snus internationally is going too far. New research shows that snus causes risks such as cardiovascular disease. Research also shows that traditional Swedish snus is culturally/aesthetically repugnant to many, and therefore snus is not a relevant product internationally.

I argue that the “Tobacco Endgame – Smoke free Sweden 2025” (www.tobaksfakta.se) is a better option to reduce tobacco-related mortality than to peddle snus internationally, a product that few outside Sweden even want.

Atakan Befrits: Snus is not a serious public health problem – Published: august 21, 2015

It is time for Karolinska Institute (KI), the Public Health Agency and the National Board of Health in Sweden to do the right thing and explain how stumblingly near zero the harm from snus actually is in Sweden. They should then refer and recommend that adult consumers make their own informed decisions.

Sweden has a unique responsibility to the world to rectify a 40-year old mistake and potentially save hundreds of millions of lives. It is not the tobacco itself, or the nicotine, that kills. It is the combustion gasses from tobacco smoking, or poor quality tobacco mixed with other dangerous carcinogens, which kill and destroy health.

According to the WHO, one billion people this century will die from smoking given the current developments. Broad international knowledge that a 99% less hazardous tobacco use is quite possible, inexpensive, and furthermore proven in Sweden since 100 years. Snus has every potential to save hundreds of millions of lives worldwide.

Is it then reasonable that Sweden, nationally and especially internationally, continues to push the line that snus is a serious public health problem, when it patently clearly is not?

Would it not be better to cooperate with our public health authorities to maximize the benefits we can realize from snus (e-cigarette) to smokers, while minimizing the use of snus (e-cigarette) among those who otherwise would never have initiated tobacco or nicotine use?

The Swedish government in June 2013 ordered an investigation to be done by the National Board of Health, the Public Health Agency and the Karolinska, to present to the government the total cost and harms to health of total tobacco consumption in Sweden. The report from the National Board could not show a single data point as evidence that snus is a serious public health problem, but clearly showed that about 12,000 die from smoking each year in Sweden. Can anyone draw any other conclusion from that, other than that the harms from snus are below relevant measurable levels in terms of public health?

  • Snus in Sweden used by 300,000 people for not smoking, it saves about 3,589 lives a year and causes up to 11 cases of cancer overall (Wickholm 2005)
  • Snus in Sweden used by 700,000 people who have never smoked, as a mild stimulant and addictive pleasure product, that results in no more than 24 cases of cancer per year, according to a Swedish study from 2005 (Wickholm)
  • The total maximum of 35 cases of cancer a year (if any at all), have for a hundred years not caught any attention from healthcare, and harm from snus is thus so low that it is not meaningful to measure (National Board of Health 2014)
  • If all of Sweden (ten million) took snus daily and nobody smoked, we would have about 12,000 fewer deaths from smoking in Sweden each year, while the snus use would cause a total maximum of 350 cases of cancer per year and no other measurable serious adverse health effects
  • Cancer warnings were removed from snus in Sweden in 2001, since not even the 35 (possible) cases of cancer per million user years mentioned above, could be verified with evidence-based science according to the European Union
  • The Public Health Agency of Sweden has actively (2015) sought to influence the FDA to not allow the removal of the cancer warning on Swedish snus sold there
  • Reduction in risk of continued tobacco use if one switches from cigarettes to snus use is 99.7% according to the figures above
  • A lifetime of snus use causes substantially lower risks than only 3 months of smoking or continued smoking does

So, snus is not harmless, but definitely not a serious “public health problem”.

Center of Public Health USA disseminates gross untruths, and won’t reply to critique

Dear Reader of this LinkedIn blog,

I hope you will believe me when I say that I try to give the benefit of the doubt, and give room for error and correction. After several attempts and reminders to get a response to a vital and lifesaving question for millions of Americans and over a Billion worldwide, I have decided to publish my letter to the NIH internal newsletter. The Newsletter should by all counts have 5,000 recipients directly employed by NIH, quite probably another 5,000 PostGrad researchers who are Intramural at NIH, and finally information from the Newsletter disseminating to another staggering 325,000 Extramural researchers funded by the NIH.

Please read below and I hope you will agree with me that it is respectful, reasonable and generally not very tinfoil hat. No response.

(Hear find link to article on Tobacco Harm Reduction in Sweden’s biggest newspaper by myself: www.linkedin.com/pulse/article/calling-out-public-health-sweden-truth-snus-atakan-befrits)

Dear Mr McManus and colleagues,

My name is Atakan Befrits and I work with Tobacco Harm Reduction advocacy focussing on the Middle East, Asia and Africa regions.

I am writing to you in response to a somewhat unfortunate report in your internal newsletter published July 17th.

I am certain that the report in question was an accurate account of a lecture held by a NIH funded scientist on NIH campus, the statements in it are certainly all hallmarks of Professor Stanton Glantz’s usual lecture commentary on electronic cigarettes in particular and Tobacco Harm Reduction in general.

The reason the report in NIH Records is unfortunate is precisely that it is just that, commentary. Extensive and conclusive commentary derived from conclusions drawn on scant, non existent, or even contrary findings in the actual research, much of which is funded by the NIH.

I scanned the other articles in the issue of The Record, which is freely available online for anyone to read. The other articles that I was reasonably able to form an opinion regarding, seemed accurate enough and penned for easy reading, also by non expert readers.

I therefore gather that the articles are intended for a wide readership, also by non experts in the specific field covered, who work within NIH.

By default, intentionally or unintentionally, there is a tremendous element of influence through this newsletter as a channel, and this influence surely reaches far and wide through the NIH grapevine.

NIH intramurally and extramurally is one of the largest research organizations on the planet and carries immense weight and influence.

Smoking is the biggest avoidable cause of death on the planet and is expected to prematurely kill one billion human beings this century, given the current trends.

Given the two sets of circumstances stated above, the NIH more than any other organization except possibly the WHO, absolutely has to get it right.

Yet in the 17th of July 2015 issue you publish an accurate report of an on campus lecture given by the (arguably) most heavily biased “Tobacco Control” researcher and anti-nicotine advocate in the USA.

Defending the publication with an argument like for example: “It is simply a report from an on campus lecture” (a very real reply from NIH to critique by another renowned voice in the field), would immediately bring on the question if the lecture by Professor Glantz was not very ill-advised in the first place.

May I be so bold as to ask who at NIH invited Professor Glantz to hold the lecture? I am curious if the lecture was pre-screened or if the content was well known in advance and sanctioned?

For your information please find enclosed an open to letter to WHO Director General Mrs. Dr. Margaret Chan from early 2014. The letter is signed by 53 Public Health experts coming from many different specialities. Together they represent some 1,325 person years of tobacco cessation and tobacco control research and advocacy.

They with one voice loudly and clearly say that Professor Glantz view on “Tobacco Control” and “Tobacco Harm Reduction” is wrong, deadly, counterproductive and based in ideology instead of evidence and/or observation.

Thank you very much in advance for your kind attention and reply

With my best regards and respect for the important work carried out by the NIH personnel and affiliated researchers.

Atakan Befrits
Tobacco Harm Reduction Advocate
Northern Cyprus

Calling out Public Health Sweden for the truth on snus, august 21st 2015

English translation of Op-Ed in Sweden’s biggest newspaper this morning, probably my only 15 minutes in the limelight:

http://asikt.dn.se/asikt/debatt/snus-ar-inte-ett-allvarligt-folkhalsoproblem/

English translation:

It is time for Karolinska Institute (KI), the Public Health Agency and the National Board of Health in Sweden to do the right thing and explain how stumblingly near zero the harm from snus actually is in Sweden. They should then refer and recommend that adult consumers make their own informed decisions.

Sweden has a unique responsibility to the world to rectify a 40-year old mistake and potentially save hundreds of millions of lives. It is not the tobacco itself, or the nicotine, that kills. It is the combustion gasses from tobacco smoking, or poor quality tobacco mixed with other dangerous carcinogens, which kill and destroy health.

According to the WHO, one billion people this century will die from smoking given the current developments. Broad international knowledge that a 99% less hazardous tobacco use is quite possible, inexpensive, and furthermore proven in Sweden since 100 years. Snus has every potential to save hundreds of millions of lives worldwide.

Is it then reasonable that Sweden, nationally and especially internationally, continues to push the line that snus is a serious public health problem, when it patently clearly is not?

Would it not be better to cooperate with our public health authorities to maximize the benefits we can realize from snus (e-cigarette) to smokers, while minimizing the use of snus (e-cigarette) among those who otherwise would never have initiated tobacco or nicotine use?

The Swedish government in June 2013 ordered an investigation to be done by the National Board of Health, the Public Health Agency and the Karolinska, to present to the government the total cost and harms to health of total tobacco consumption in Sweden. The report from the National Board could not show a single data point as evidence that snus is a serious public health problem, but clearly showed that about 12,000 die from smoking each year in Sweden. Can anyone draw any other conclusion from that, other than that the harms from snus are below relevant measurable levels in terms of public health?

• Snus in Sweden used by 300,000 people for not smoking, it saves about 3,589 lives a year and causes up to 11 cases of cancer overall (Wickholm 2005)

• Snus in Sweden used by 700,000 people who have never smoked, as a mild stimulant and addictive pleasure product, that results in no more than 24 cases of cancer per year, according to a Swedish study from 2005 (Wickholm)

• The total maximum of 35 cases of cancer a year (if any at all), have for a hundred years not caught any attention from healthcare, and harm from snus is thus so low that it is not meaningful to measure (National Board of Health 2014)

• If all of Sweden (ten million) took snus daily and nobody smoked, we would have about 12,000 fewer deaths from smoking in Sweden each year, while the snus use would cause a total maximum of 350 cases of cancer per year and no other measurable serious adverse health effects

• Cancer warnings were removed from snus in Sweden in 2001, since not even the 35 (possible) cases of cancer per million user years mentioned above, could be verified with evidence-based science according to the European Union

• The Public Health Agency of Sweden has actively (2015) sought to influence the FDA to not allow the removal of the cancer warning on Swedish snus sold there

• Reduction in risk of continued tobacco use if one switches from cigarettes to snus use is 99.7% according to the figures above

• A lifetime of snus use causes substantially lower risks than only 3 months of smoking or continued smoking does

So, snus is not harmless, but definitely not a serious “public health problem”.

Author
Atakan Befrits​

FDA (And the EU) want to kill E-cig (and thereby people) but the UK say they are fantastic!

In a comment to the FDA on their work to ultimately regulate e-cig totally out of business for any actor not Pharma or Transnational Tobacco or other International FMCG enterprise like Nestlé or similar. Simply by making the FDA process so onerous, time consuming and uncertain that only companies with a couple of million dollars in pocket change per every 6 months or so will ever have a chance. Especially so since any problem will mean sunk money and lost months of vital revenue. Completely unnecessary deeming regulations will be put in place instead of reasonable consumer protection and child protection measures like with other products, um yeah, like cigarettes for example.

This is pretty much what I wrote to them in a comment:

I am commenting on ANPRM “Nicotine Exposure Warnings and Child-Resistant Packaging for Liquid Nicotine, Nicotine-Containing E-Liquid(s), and Other Tobacco Products” (Docket No. FDA-2015-N-1514)

August 18th, 2015

Dear FDA,

My name is Atakan Befrits and I am a THR consumer and advocate (Snus and vaping products with high nicotine concentrations). I fully support tamper and child resistant packaging and reasonable and appropriate warning labels, reasonable requirements that will not prove overly onerous or prohibitively difficult to include unless the FDA make them so.

I strongly object to any form of overly ambitious regimens for producers, to satisfy requirements from the FDA, that serve no practical purpose for consumer protection. The current proposed deeming regulations serve no such practical purpose for consumer protection but serve well to protect both smoking and protecting large industrial actors (such as the Tobacco Industry) if and when they chose to intensify their efforts in sales of reduced harm consumer nicotine products. I am, smoke-free thanks to snus (before e-cig were invented) and also with a lot of pleasure and very little harm from occasionally using e-cig. This does not make me more prone to relapsing to smoking cigarettes, it makes me less prone to do so.

I have hundreds if not thousands of instances of inadvertantly swallowing entire pouches of snus and also spilling e-liquid in larger amounts on my skin or splattering in my eyes without any other effects than slight discomfort. Furthermore I would like to add that in the 70’s my mother rushed me to the hospital no less than 4 times to get my stomach pumped after eating cigarettes or cigarette butts. It is now perfectly clear that these instances were completely unnecessary traumas for me, since overdose of nicotine would have induced vomiting and solved the problem. Not unlike most other forms of food poisoning or accidental ingestion, but not applicable to most of the very easily accessible household chemicals causing countless hospitalizations and several (too many) child fatalities every year.

All of the refills and snus products that i buy are already in child resistant packaging and with clear +18 warnings and produced according to food grade standards or GMP.

I keep all my tobacco out of reach for my 2.5 year old. Her access to bleach, detergent, kitchen knives, table top sharp edges and about a million other hazards are infinitely more accessible to her than my nicotine products.

If there will come overly ambitious warnings or claims on e-liquid or smokeless products it would make me angry and less likely to ever trust other information that comes from the FDA. I know quite a bit about who wants what in terms of e-liquid and other nicotine products. From the end result I will therefore also know who was most successful in “swaying” the sentiments of the FDA in any particular direction. Any deviation from a science and evidence based center position by the FDA will be completely evident, including an unwarranted “precautionary principle” direction. FDA knows more about nicotine and nicotine containing products than most other consumer products and there simply is nothing left to be very afraid of, therefore very little need of further precaution.

Simple science based regulations empowering consumers to exercise tobacco harm reductions while protecting children and never users is quite sufficient. No more and no less!

I am a member of CASAA as well as internationally active in the Tobacco Harm Reduction field globally, with a special focus on the Middle East, Asia and Africa regions.

I would like to point out to the FDA that too onerous regulations in the USA will, without any doubt whatsoever as it is already happening, send signals to the rest of the world that Low Risk Nicotine products are actually HIGHER in risk compared to conventional cigarettes. The amount of regulation and the amount of paperwork required in the USA in their eyes reflect the amount of risk with the product.

Too high demands and too onerous processes by the FDA will be quite detrimental to US consumers, and will have the unintended consequence of inadvertently causing hundreds of millions of deaths outside the USA this century through protecting cigarettes from low risk competition. Exactly the opposite of what we all strive for.

The FDA and the EU SANCO and the WHO are the world’s largest net exporters of Health Policy. It is therefore absolutely imperative that also the “bigger picture” implications are factored in when deciding on policy, simply looking at the USA exclusively, although correct in principle, would be to grossly underestimate the impact FDA policy has on Health Policy in LMIC countries globally.

Thank you very much for your consideration,

Atakan Befrits

Turkey/Northern Cyprus