Monthly Archives: January 2016

FLASH – Sweden is trying to BAN all THR!

Published January 26th in Dagens Nyheter – Translated by Atakan Befrits

Dagens Nyheter is Sweden’s biggest and arguably most influential national newspaper.

UPDATE UPDATE – As expected a bill was presented on February 2nd. The Government vehemently denies any negative changes to snus, and completely skirts the issue of e-cig regulations. Find the bill in Swedish here: Bill fulltext

If you are interested in the wording that effectively bans snus for THR purposes (may still be sold as evil tobacco product on par with other products such as cigarettes and betel quid) find the text translated here (page 39 in the bill). 

As regards smokeless tobacco products, these shall, in accordance with Article 12 of the Directive, bear a health warning “This tobacco harms health and is addictive”. Swedish Match has made it clearer formulation of the health warnings to be shown on snus is not factual and lacks scientific support. The preamble to the Directive states that tobacco products are not ordinary goods and with regard to tobacco particularly harmful impact on human health, health protection should be given high importance. There is no doubt that the use of tobacco is addictive and associated with health risks. The Government therefore considers that warnings which are now proposed to be introduced on smokeless tobacco products is justified.
Overall, the Government believes that tobacco product directive bestämm- Started on health warnings and combined health warnings could be implemented in the law without being in breach of the Press Act.
Not at all unsurprisingly the justification for raising the warning on snus is that OTHER tobacco products are dangerous. 

This article is one in a series in various media channels that are, beginning to look like a concerted effort by Anti-Nicotine groups; in order to fully justify the harsher legislation on Snus and E-cig products in Sweden within the next few days. Scheduled presentation to Parliament of the bill is February 2nd.

That this only protects cigarettes seems to be a very minor detail, since “we all know” that cigarettes will soon be gone 😦

The results will be as follows:

  • FDA will say no to Swedish Match Modified Risk Tobacco Products application.
  • Sweden will have a de facto total ban on nicotine containing E-cig products.
  • Harsher warnings on snus will significantly reduce switching from smoking to snus.
  • Snus technology exports and implementations to regions in the world where few can afford vaping products will be impossible.
  • The list is long

Since there is not one iota of evidence to support these actions, the Government is finalizing it’s political “truth”

Dear reader, it may interest you that this author’s previous position was as acting editor-in-chief for a large Pharmaceutical Business Magazine, that ought to be grounds for being disqualified against discussing and voicing opinions on an imminent legislative issue with huge potential benefit for the Pharmaceutical Industry. Unfortunately it seems that the editor-in-chief of Dagens Nyheter must hold a diametrically opposing view to mine, regarding how influence works and should best be avoided/promoted.

There is unquestionably a high probability of good understanding of the subject matter by the writer, but also a high likelihood of cronyism. The very clear partisanship (only slightly glossed over) in the article, either way makes this an extremely unethical article.

The e-cig issue is being decided imminently, and a total de facto ban is more than likely. In these same days the Government in Sweden is also proposing to RAISE the warnings on “Swedish Food Grade Low Nitrosamine Smokeless Tobacco” aka “snus” in a fashion totally unsupported by evidence based or observation based science.

Here is a straight translation:

Comment. To use e-cigarettes linked to higher use of regular cigarettes among US adolescents, according to a new study.

Amina Manzoor

Last fall, I was at the European Congress on respiratory diseases. It presented many hundreds of research studies in many different subjects, but what drew the most audience was a debate about e-cigarettes. It was probably also one of the most highly charged debates I’ve seen. The researchers presented preliminary research on the harmful effects of e-cigarettes were accused of wanting to get people to smoke regular cigarettes, and for being corrupt.

E-cigarettes are often marketed as a healthier alternative to regular tobacco cigarettes and as a way to quit smoking. That e-cigarettes are better than regular tobacco cigarettes, few disagree with. But more and more research suggests that they are probably not the solution they are presented as.

Recently The Lancet Respiratory Medicine published a compilation of 38 studies of e-cigarettes to quit smoking. The result? Anyone who used e-cigarettes had less chance to quit smoking regular cigarettes. Contrary to what the marketing says, that is. Other studies have shown that e-cigarettes can contain hazardous substances.

Today The BMJ published a study on American youth that suggests that anyone who tried e-cigarettes are also more inclined to test regular cigarettes. One should be careful not to over-interpret the results, because it is not possible to say anything about the underlying mechanisms, because of the study methodology.

This is also a study of American adolescents, and therefore it may be difficult to extrapolate this to Swedish youth, But the results are in line with another US study last fall.

These are still signs that should be taken seriously. In a Swedish report more school youth state that they have ever tried e-cigarettes, compared to the year before. Since there is no age limit on e-cigarettes, these may be easier to obtain than regular cigarettes.

The MPA (Medical Products Agency) want e-cigarettes containing nicotine to be classified as pharmaceuticals, which would give better control. However, the decision was appealed and it is now up to the Supreme Administrative Court to decide. I understand the vigilance from some researchers and government authorities. Tobacco smoking is going down in society, but if e-cigarettes are a gateway to regular cigarettes, then there is a risk that we will have a new generation of smokers in a few years. And I think that few people want that.

Photo:

Facts: The study was done in Hawaii

The study included 2,338 schoolchildren who were in the ninth and tenth grade in Hawaii, USA. The average age was just under 15 years. They were asked to answer questions about smoking habits in 2013 and were followed up a year later. According to the study, the use of e-cigarettes at baseline was associated with a three times higher risk of testing regular cigarettes after one year.

Source: BMJ

For further information or questions please contact:

atakan.befrits@gmail.com

Swedish Public Health truthless on snus

Left-overs, but important left-overs, from 5 months ago. Please note that the exchange is backwards, from last published entry to first.

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?

Will Public Health in Germany try the same with the Quorum on implementing the TPD2 (Tobacco Products Directive 2), C/O Frau Pötschke-Langer?

It should be noted that the Health Minister, Public Health Agency and the National Board on Health and Welfare all actively declined to reply to my critique. Only the Institute responsible for awarding the Nobel Prize in Medicine saw fit to reply.

Prima facie this could be viewed as legitimizing the negative view on snus, but in light of the current debate and the current science, seems more a testament to Swedish Public Health being absolutely rotten, right to the core.

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 far 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 / peoples 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? Probably distinctly positive for the Cigarette End-Game though.

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 aesthetic culture? Moreover also, without foreign influences? (How does that play with the soundbite that Big Tobacco is the cause of  the still growing smoking epidemic?)

300 million people worldwide are using extremely dangerous forms of smokeless formulations (very very dangerous snus, simply put, often with low tobacco content too), in their case it is definitely a question of a local cultural expression, compared with Sweden’s about 1 million snus users, in a 10 million population.

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 bans 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 may not be entirely harmless, but is definitely not a serious “public health problem”.

THR SWEDEN vs. WORLD 31.12.2015

CigdeathSnusdeath

Lay-man to Lancet on E-cig and “desk-murder”

Sir,

You will be getting an absolutely massive amount of flak today, due to the publication of Professor Glantz metastudy.

The study itself, though not on it’s own volition, points out something very very clearly: Public Health knows nowhere near as much as they would need to know, to speak out with the kind of authority that they do on e-cig.

One of the few available sources to use for a ”reality-check” of articles like the Glantz study is, believe it or not, Sweden.

I have written extensively on the fact that nowhere in the health chain in Sweden, from neonatal to post mortem, has there ever been raised a clinical concern regarding harms resulting from food grade smokeless tobacco aka ”snus” use in over 100 years.

Over 10% of the male adult population in Sweden have been 12-hour-a-day-their-entire-adult-lives users of the product for over 100 years. At least 3 full generations of users, yet no clinical mention of harm or suspected harm. That is remarkable, extraordinary and should be very very comforting and reassuring. Actually this is not entirely different from a “security blanket”, but for Public Health professionals, who do seem very anxious about venturing outside their safety zone.

Not unlike coffee, the harms are so low that only lab cultures, and culture based population modeling even come close, to accurately measuring them. In the case of coffee it also seems that the benefits FAR outweigh the risks.

In all likelihood nicotine use without combustion and without toxic additives or production methods will ultimately end up on par to coffee.

The real issue that ought to be studied, but never has, is this:

Since the inclusion of snus in the Swedish Food Act in 1971, and since there are no demonstrative harms, what positive effects on public health has this product had in Swedish society?

If the answer would be zero or negative or positive, fine. Either way, the findings from such a study would signal better study regimes and better questions when studying e-cigarettes.

The problem is that the best intervention (besides just plain quitting, by far the best option) per capita to date, simply has not been studied at all, due to reluctance, obstruction really, from Swedish Public Health.

E-cig and snus should be globally promoted to smokers immediately, and effects, efficacy and side-effects closely monitored for tweaking.

Anything less, given what we know already, is nothing other than “desk-murder”

CigdeathSnusdeath

Actual published numbers from an actual country actually on earth:

NorwaySnus2000-2014 with vaping

Op-ed fact lies accepted, corrections not:( Bad form DN!

Please accept my apologies for Swedish only

Beskriv vad som ska rättas i följande artikel: http://www.dn.se/debatt/skydda-barn-och-unga-mot-riskerna-med-e-cigaretterna/

REPLIK/RÄTTELSE

Public Health England gick den 19e augusti 2015 ut med en bred pressinformation att riskerna med E-cigaretter av rimlig kvalitet är minst 95% lägre än riskerna med rökning. I Storbritannien finns 10 miljoner rökare, det är osannolikt att Folkhälsomyndigheterna skulle rekommendera e-cigaretter om man inte var säker på siffran 95%.
Betyder det att 95% säkrare inte är tillräckligt säkert i Sverige? Jag måste anta det då artikelförfattarna är hårda motståndare även till Svenskt snus. Svenskt snus är 98% mindre skadligt jämfört med cigaretter. Svenskt snus har på 200 år inte registrerat några allvarliga skador i Sverige men rökning dödar 11,881 personer om året enligt Socialstyrelsens rapport från 2014.
Vi skall alltså på fullaste allvar, så långt det är möjligt, försämra marknadsförutsättningarna för skadereducerade nikotinprodukter som snus och e-cigaretter att konkurrera ut riktiga cigaretter, och tro att vi därmed motverkar rökning?
Blir inte den logiska slutsatsen i stället bli precis tvärt om?
Detta gäller förstås endast om det inte är en dold strategi, att alla som använder nikotin i så hög utsträckning som möjligt SKALL dö av rökning i avskräckande syfte, så framtida generationer låter bli nikotin helt och hållet?
Snus går med säkerhet inte att skilja från nikotinläkemedel i termer av allvarliga skador. Ingen av produkter tillåts (egentligen) till konsumenter under 18 och ingen av produkterna skall användas under graviditet. Det finns inga seriösa vetenskapliga tecken hittills, att långsiktigt användande av e-cigaretter skulle påverka siffran 95% mindre skadligt, annat än möjligen höja siffran till samma nivå som snus, det vet vi först på 25 års sikt.
Färre unga röker och fler provar alternativ, så är det år 2016 i västvärlden
Det är inte dåligt, det är bra!
Det är fantastiskt bra till och med om man jämför med utvecklingsländer där cigarettrökningen bland unga fortfarande växer, eller i bästa fall är stadig
Om Sverige inte tar sitt ansvar och deltar i kampen mot rökning, också genom förespråkande av mindre farliga produkter, så visar kurvorna nedan att WHO har rätt; Ca EN MILJARD människor kommer att dö av rökning innan 2100.
Bara i lilla Sverige är situationen väsentligen annorlunda, och vi vägrar att berätta hur och varför.
Är det rätt väg till ett rökfritt samhälle?
Är det ens en fungerande väg till ett rökfritt samhälle? särskilt som Svensk folkhälsopolitik är en viktig exportprodukt till resten av världen!
Rökning globalt:

Smokingisrising

Rökning i västvärlden:

THR SWEDEN vs. WORLD 31.12.2015

De fyra punkterna borde i folkhälsans namn istället vara
1. Inför åldersgräns och Infoga snus och e-cigaretter i vårdens samtliga insatser mot rökrelaterad ohälsa
2. Tillåt måttlig marknadsföring av snus och e-cigaretter riktade endast till rökare (som nikotinläkemedlen idag) och tillåt smaker på snus och e-cigaretter
3. Övervaka kontinuerligt hälsoeffekterna av byte till lågrisknikotin för löpande “bästa vetenskapliga och evidensbaserade råd” till rökare och användare av lågrisknikotin
4. Tillåt e.cigaretter i anvisade utrymmen (ventilerade) inomhus och slopa snusförbud på arbetstid. Allt för att göra omedelbart byte från cigaretter så attraktivt som över huvud taget möjligt
Se nedan rökning i Norge, när snus gjorde brett intåg och sedan 10 år senare när e-cigaretterna tog fart.
NorwaySnus2000-2014 with vaping

Largest independent E-cig survey

Survey analysis of CASAA.ORG survey November and December 2015

CASAA – The Consumer Advocates for Smoke-free Alternatives Association.

Independent US association with global network advocating Harm Reduction policy to reduce harms from smoking.

Casaa has 122,000 registered members

Credits to CASAA for performing the study and to Carl V. Phillips for writing the analysis and sharing it.

At the end of 2015, CASAA conducted a survey of e-cigarette use, targeted at CASAA members who are adult U.S. residents. The survey was designed primarily to provide information relevant to evaluating FDA’s proposed “regulation” (i.e., ban) of e-cigarettes. We reported some of the results in our report to OIRA regarding the proposed regulation. What follows here is a bit more detail.

Methodology and numbers of observations

The survey was conducted in November and December of 2015. It was a self-administered online survey that took approximately five to ten minutes to complete. The target population was adults living in the United States who are CASAA members. CASAA membership was approximately 120,000 at the time of the survey. We were able to directly contact approximately 77,000 members via email (the others did not opt in for receiving emails from CASAA) to invite them to participate. An initial invitation and two reminders were sent via email, as well as two additional reminders to those who did not open one of the other rounds of emails.

A (different) collector link was also shared via CASAA social media to attempt to reach members who did not receive the email. The target population was clearly stated in these communications, but others could respond to the invitations and were allowed to take the survey.

A total of 27,343 subjects completed the survey. Of those, 20,454 indicated they were CASAA members. After excluding the CASAA members who indicated they do not live in the USA and a few who indicated they were under 18, a target population of 20,162 observations remained, 18,214 of whom indicated they received the email invitation.

Of the target population, 106 had never been e-cigarette users, as defined by not having spent a total of $100 on e-cigarette products for personal use. (All CASAA members were encouraged to participate, regardless of e-cigarette use status.) No further substantive questions were asked of this subgroup. Of those remaining, 238 indicated that they were not currently regular e-cigarette users, as defined by not having used an e-cigarette on 10 occasions in the last week. They were asked just two substantive questions. (These screening questions were both piloted, and it was clear that the target audience had no difficulty answering them.)

The statistics presented here are for the remaining 19,823 regular current users among the target population. Analysis of the 238 and comparisons of results for the excluded subpopulations are not included in the interests of parsimony. There were multiple branches for part of the survey, based on reported smoking and smoking cessation history.

Note that I am not going to waste time with the busy-work of reporting confidence intervals. Anyone who understands what they mean will know that for a sample of 20K that is undoubtedly a somewhat biased sample of the target population, such reporting falls somewhere between useless and misleading. More substantively, I have not manually parsed the “other” open-ended answers to recode responses that really belong in one of the set categories, and there definitely are some of those. I will leave that, deciding what to do with the (seemingly few) incompatible answer patterns, and also comparing the excluded subpopulations, as exercises for others (see final paragraph of this post).

Description of the study population

Because this survey targeted the CASAA membership, it is the best-defined population of any survey of e-cigarette users to date, other than a few population representative surveys that have included only a couple of basic questions about e-cigarette use. Most previous surveys lacked clearly-defined target populations; they recruited respondents via untargeted social media snowballing, and thus collected a convenience sample of responses. I am aware of only two published surveys that were based on a better defined population, customers of a particular company — one by my research group (the first published survey of e-cigarette users) and one by Siegel et al. — but both of those had such low response rates that they were effectively convenience samples. The response rates for this survey is still low enough (17% of all members; 23% of those on our email list) that we should assume there is nontrivial selection bias, based on level of social networking enthusiasm about taking surveys. But this is still far better than the <1% response rate from eligible respondents from all previous surveys targeted at e-cigarette users.

CASAA members who use e-cigarettes are clearly not representative of all U.S. e-cigarette users, given that they self-selected to participate in CASAA Calls to Action (advocacy alerts) or were otherwise interested in joining the organization. We believe the results are reasonably representative of 1 million, perhaps as many as 2 million, who are actively enthusiastic about e-cigarettes, though some results will represent the perhaps 5 million other dedicated e-cigarette users in the USA. In particular, the responses indicate a much larger portion of survey population quit smoking entirely, as compared to all e-cigarette users. However, stratified on the resulting subpopulations — those who quit entirely using e-cigarettes and those who merely reduced their smoking — the responses are probably reasonably representative of the larger population. The responses to the questions about planned actions in the event of bans are probably only representative of the enthusiast population, given that plans to seek alternative markets requires knowledge and social connections in the e-cigarette space.

Respondents were overwhelmingly open system users, with 97% reporting that is what they primarily use and another 1% using them sometime in the last month. 10% reported that they used disposables in the last month, and 14% had used rechargeable cartridge systems.

Respondents were 75% male. 14% were age 18-25, 30% 26-35, 44% 36-55, and 12% over 55.

Smoking history

87% indicated they quit smoking (entirely) after staring to use e-cigarettes. 5% still smoked sometimes. 3% had already quit smoking before starting to use e-cigarettes. The others were divided among 3% who had never been regular smokers (defined based on smoking an average of more than one cigarette per day on most days for at least a year, which is a narrower, and more meaningful, measure of having been a smoker than is typically used), 3% who gave an “other” answer, and a few who did not answer. (As noted above, this should be considered as describing the study population, rather than being a result about a larger population. This is a far higher rate of complete smoking cessation than among all e-cigarette users or even among dedicated e-cigarette users.)

Almost everyone reported previous attempts to quit smoking, with only 6% reporting no attempts before they started using e-cigarettes.

  • 71% had tried to quit using NRT,
  • 41% using some other pharmaceutical (e.g., Chantix),
  • 21% had tried formal counseling,
  • 21% had tried calling a quitline,
  • 81% had tried unaided quitting,
  • 8% volunteered some other method they tried.

Of the five specific methods (NRT, other pharmaceuticals, counseling, quitline, unaided), 8% had tried all five, 21% had tried 4 or 5, and 46% had tried at least three.

When this analysis is restricted to those who quit completely with e-cigarettes, all of the rates for quit methods increase (i.e., those who ultimately quit had been rather more intent on quitting before using e-cigarettes; keep in mind they were already 87% of the study population). The numbers are 75% for NRT, 43% for other pharmaceuticals, 24% for counseling, 24% for quitlines, 85% for unaided, and 8% for other.

For the 980 respondents who indicated that they still smoke,

  • 34% reported less than one cigarette per day on average,
  • 42% smoke one to five per day,
  • and 23% more than 5.

The remainder declined to answer.

51% of those who had not quit smoking entirely credited e-cigarettes with helping them almost quit smoking and another 44% credited e-cigarettes with helping them smoke a lot less. Only 3% indicated they use e-cigarettes as a partial substitute but still smoke almost as much as they used to, with almost none saying they smoke fully as much as they used to. A few (1%) indicated they both reduced their smoking, but do not credit that to e-cigarettes.

Of the 565 respondents who quit smoking before taking up e-cigarettes,

  • 48% indicated they were concerned they would start smoking again and so sought a substitute,
  • 31% did not predict they would start smoking again but missed it and started using e-cigarettes because of that,
  • 21% chose neither of these (they gave an open-ended answer).

Of the 17,186 respondents who quit smoking using e-cigarettes,

  • 64% indicated they switched almost immediately, within a few days of starting e-cigarettes,
  • 21% used both for longer than that but quit smoking within a month,
  • 11% used both for between one and six months before quitting smoking,
  • 3% for more than six months.

(Note that this might be best interpreted as a descriptive statistic for the study population rather than a result, per se. It seems to represent a faster average switching trajectory than we believe is average for the population overall.)

When asked about the role e-cigarettes played in their smoking cessation,

  • 64% said they started using e-cigarettes with the intention of quitting smoking,
  • 25% started with the intention of merely reducing their smoking but ended up switching entirely,
  • 11% started using e-cigarettes without the intention of quitting or reducing smoking, but ended up switching entirely.

Only a handful indicated they did not credit e-cigarettes with their successful smoking cessation. 99% indicated they believe they would still be a smoker were it not for e-cigarettes.

Role of flavors

Returning to the full population under consideration here, the percentage reporting using particular flavor categories regularly (defined as at least sometimes in a typical month) were:

  • tobacco 19%;
  • menthol/mint 18%;
  • fruit or fruit beverage 83%;
  • candy, soda, or pastry 76%;
  • spice or savory (e.g., cinnamon, clove, pepper) 30%;
  • bitter (e.g., unsweetened coffee, whiskey) 12%.

When asked about how often they choose sweet (fruit, candy, pastry, soda) flavors, 78% indicated that is what they used most or all the time (18% always, 35% almost always, 26% most of the time), with 14% using them some of the time and 7% rarely or never.

This contrasts with the proportions choosing tobacco or menthol flavors, with 48% saying never, 25% rarely, 14% some of the time, and only 11% most or all the time. 31% said they started out using tobacco or menthol flavors but now always or almost always use other flavors.

Of those who quit smoking entirely, 72% credit interesting flavors with helping them quit. Of those who still smoke, 53% say interesting flavors are helping move them toward quitting entirely.

Only 4% indicated that they do not care much about flavors and will use anything or whatever is cheapest. 43% said they use five or fewer flavors in a typical month, while 28% said they use over twenty in a typical month.

Medical advice

Subjects were asked about advice they had received from a healthcare provider about e-cigarettes, excluding counselors specifically consulted about smoking cessation. (This question was motivated by OIRA previously indicating an interest.) 35% indicated they had never talked to a healthcare provider about e-cigarettes. Of the remaining 65%, the proportions received the following bits of advice from one or more providers were (if they received different advice from different providers, they were instructed to indicate all that apply):

  • a provider got the subject interested in e-cigarettes in the first place, 10%;
  • a provider volunteered a recommendation to try e-cigarettes, though the subject was already using them or considering it, 10%;
  • subject told the provider about his/her e-cigarette use and the provider encouraged continuing, 66%;
  • subject told the provider who discouraged continuing, 5%;
  • subject told the provider and got a neutral response, 26%;
  • a provider told the subject that e-cigarettes are low-risk, 34%;
  • a provider told the subject that e-cigarettes pose high risk 3%.

Response to FDA ban scenarios

Subjects were asked about what they would do under three different scenarios under which e-cigarettes were totally or partially banned. These were described as being plausible scenarios for the USA, though no further details were mentioned. Most respondents presumably knew that if one of these happened, it would be due to FDA action. The first scenario is unlikely, but not impossible. The second is what is predicted to occur under FDA “deeming” after a grace period. The third has been rumored to be FDA’s intention to implement immediately, before the grace period expires.

Under the first scenario, e-cigarette sales would be completely banned. For this and the other scenarios, it was made clear that possession and use would still be legal, and the ban would only affect sales. Subjects were instructed to indicate all that applied if they believed they would respond with more than one of those on the list. Subjects indicated they would respond to that ban as follows:

  • quit using e-cigarettes and all tobacco/nicotine products, 5%;
  • start smoking or increase how much I now smoke, 21% of those who had quit entirely, 50% of those who still smoked;
  • start using some other smoke-free tobacco/nicotine product (e.g., snus / smokeless tobacco; NRT) or increase my current use of those products, 4%;
  • continue to use e-cigarettes, getting products and supplies (e.g., e-liquid) from overseas or the domestic black market and/or by making them myself, 93%.

The second scenario was a ban of all products except for a small variety of closed-system cigalikes, which would only come in tobacco and menthol flavors. It was noted that these would be more expensive than current cigalikes. The responses were:

  • this would not affect me because I currently only use cigalikes that are tobacco or menthol flavored, 1%;
  • use the cigalike products that could be sold legally, 4% (note that this should be a superset of the previous 1%);
  • quit using e-cigarettes and all tobacco/nicotine products, 6%,
  • start smoking or increase how much I now smoke, 21% of quitters, 46% of those who still smoke;
  • start using some other smoke-free tobacco/nicotine product (e.g., snus / smokeless tobacco; NRT) or increase my current use of those products, 4%;
  • Continue to use my preferred type of e-cigarettes, getting products and supplies (e.g., e-liquid) from overseas or the domestic black market and/or by making them myself, 91%.

The third scenario was that all types of e-cigarette hardware would still be available (cigalikes and open systems), but all e-cigarettes and e-liquid sold could only be tobacco or menthol flavored. The responses were:

  • this would not affect me because I currently only use tobacco or menthol flavors, 4%;
  • switch to using only tobacco or menthol flavors, 10% (which includes some of the previous 4%, though the wording makes this a bit ambiguous);
  • quit using e-cigarettes and all tobacco/nicotine products, 5%;
  • start smoking or increase how much I now smoke, 14% of quitters, 35% of those who still smoke;
  • start using some other smoke-free tobacco/nicotine product (e.g., snus / smokeless tobacco; NRT) or increase my current use of those products, 3%;
  • Continue to use my preferred flavors of e-cigarettes, getting e-liquid (or flavored cigalikes) from overseas or the domestic black market and/or by making or flavoring e-liquid myself, 89%.

Discussion

It is worth noting that even without extrapolating the results to the larger population, this survey population includes 17,000 Americans who attribute their successful smoking cessation to e-cigarettes. If we estimate e-cigarettes to post about 1/100th the health risk of smoking, the net population health benefits would only be offset if most of 2 million non-users became regular users of e-cigarettes, far more than have done so (and that is ignoring the net consumption benefits, which would necessarily be positive for those who choose to become new users). If we extrapolate that to the larger population it represents, we get close to requiring every single American take up e-cigarettes to offset the health benefit alone.

The results about NRT — the large percentage of those who quit with e-cigarettes who had failed to quit with NRT, as well as the lack of interest in switching to any smoke-free alternative under the ban scenarios — starkly illustrate the failure of those products. The reasons these theoretically similar products vary so hugely in terms of actual quality are widely discussed, but it would be interesting to conduct some more organized survey research on that point.

The results about flavors are simply another confirmation of what everyone with any expertise has known for years: The “proper” e-cigarette users (adults who used or are using them to quit smoking) overwhelmingly prefer and choose interesting — usually sweet — flavors, and that these flavors play a major role in smoking cessation. Choosing them is the equilibrium state for most vapers.

The responses to the ban scenario questions are the particularly useful bits of this survey. While a few other surveys have produced generally similar results, the present survey specified more concrete and plausible scenarios, and the survey population and who they represent is far better defined. About 90% of the study population — which it seems safe to extrapolate to over a million Americans — would pursue black, grey, and/or do-it-yourself markets in the event of any severe restriction on their preferred e-cigarettes. Notably, the ban of interesting flavors alone prompts almost as much interest in those options as does a total ban. Discussion surrounding this survey revealed a large portion of enthusiast vapers declaring they are personally dedicated to being the black market, if necessary, rather than just using it.

(Note that we considered breaking out the alternative markets into separate answers, but pilot testing suggested this was not practical. On further reflection, we concluded that a stated intention to seek alternative supply is fairly robust, but any speculation about how that would be done — not knowing how the alternative markets would evolve — would be unsubstantiated speculation.)

Even as most respondents indicate they would simply defy the bans, their responses suggest such bans would also cause a dramatic increase in their smoking. This effect alone would dwarf any supposed benefits of the bans. Very few respondents indicated a willingness to choose one of the options that they are “supposed to do” (as defined by ban proponents).

Policy recommendations

Wait, you think I would suggest that a single study’s results, absent any analysis of the ethics or effects of actual policies, are sufficient to recommend a particular policy? Do I look like a “public health” “researcher”?

But seriously, see our OIRA report, in which I do the policy analysis. Most notably it points out the implications of alternative markets, which this survey confirms are inevitable. They would be robust but far inferior to the status quoin every way. The result would be that the proposed FDA bans will accomplish literally none of their goals and will set many of them back. Neither FDA nor any other proponents of bans have ever admitted, let alone serious analyzed, what will really happen.

Further analysis

If anyone would like to suggest any further analyses of the data (crosstabs or whatever) that seem particularly interesting, please mention them in the comments. I will see what I can do. All of the questions asked in the survey are represented in the reporting above.

We will be making the data, detailed methods (i.e., exact survey instrument and all notes about its development), and the R code I used for the above available to external researchers who want to turn it into a journal paper (and to check my work! — a rarity in the world of public health research). If you are interested, and have a history of doing honest high-quality research on or around this type of data, email me.

Harm Reduction is plain EVIL in Sweden

Happy New Year Everyone!
There has been a massive and concerted anti-THR effort in Sweden this Silly season.
Absolutely all news outlets picked up on a re-released statement from the Norwegian Doctors Association calling for a total and lifelong ban on purchasing all forms (especially snus of course) for anyone born after the year 2000. This is called “phasing out tobacco from society”. In theory this is against all forms of common sense and choice discussions, but if only applicable to combustibles, at least probably healthy for those who heed the ban. Everyone else loses.
Sweden picked up beautifully on the (staged?) cue from Norway and went absolutely haywire. Doctors against tobacco, who pretty much run the show, went public and stated that the entire arsenal in the FCTC and much much more, should be invoked to once and for all end the scourge of tobacco use. Any mention of Harm Reduction for tobacco users, also clearly stated in the FCTC was conspicuously absent. Any note of also tobacco users having human rights in line with the rights stated clearly in the convention equally absent.
This morning there is a HUGE attack on vaping in Sweden’s largest newspaper, Dagens Nyheter, spewed forth by A Non Smoking Generation (started 1979) and an anti-nicotine youth organization called Smart Youth.
Mutagenic (Oooh, nice catch, thanks to Knapston at The Telegraph and the formidable global ANTZ network, they are better than Burston Marsteller),Formaldehyde, cytokines, acetaldehyde, acrolein, glyoxal and methylglyoxal. Add to this particulates, nickel, tin, chromium. They say that 9 of 11 found toxicants are present in equal or higher concentrations compared to regular cigarettes. (which 9 out of which 11??)
Furthermore youth buy these products when they cannot get a hold of snus or cigarettes, and this is a hugely bad and terrible thing.
Furthermore nicotine is a fantastically toxic and horrible substance in and of itself. E-cig therefore are a perfectly clear and proven “gateway” to snus use, to cigarette smoking, and to narcotics.
They want:
1. No sales to minors (C’mon, everybody agrees on this)
2. Ban ALL flavors except possibly tobacco
3. Ban ALL marketing
4. Include vaping in ALL smoke-free areas
Make no mistake about this: This is an effort to secure TPD2 or higher regulations on e-cig/vaping. This is an effort to secure an elevation of the warning labels on snus from “may cause harm” to “causes harm”.
This last piece of “snus” legislation is planned for this January, pretty much exactly 2 months BEFORE Swedish Public Health have promised to finally release a report that tries to quantify the harms from snus use.

Those of us who are reasonably well acquainted with ANTZ tactics and strategy of course immediately realize that FDA will NEVER certify a product as “Modified Risk Tobacco Product” that just had it’s warning label ELEVATED in it’s home country.

A product class that just got it’s 114,000 page and 10 million dollar “MRTP” application denied by the US FDA in 2016, and also had the warnings ELEVATED at home in the Public Health paragon Sweden, also in 2016:

THIS PRODUCT WILL NEVER BE USED FOR THE PURPOSE OF REDUCING HARMS FROM CIGARETTE SMOKING ANYWHERE IN THE WORLD, EVER.

Is there any chance of stopping a global (outside Scandinavia and North America) de-facto ban on a 98% harm reduced tobacco product as alternative to lethal smoking?

Unfortunately, probably not

The timing and effort and obvious preparation of this campaign in Sweden is truly staggering in it’s covertly global implications.
This is so truly Machiavellian in design and execution that I must take my hat off and congratulate them on a job marvelously well done
Since the report will be irrelevant when it comes, since “Snus causes harm” is already law, they are therefore free to lie about as much as they want to nicely fit with the legal definition. Lovely, just lovely!
The actual answer came already in September 2013 from the Karolinska Institute. Nothing has ever been really reported, found or measured in 200  years of use and clinical practice. Therefore, since the answer is certainly awfully close to ZERO but we can’t have that, more money for research was urgently needed and earliest possible time for preliminary indications on harms from Snus was advised for march 2016. See article on this farcical Public Health sham and utter disgrace here: Something is ROTTEN in the tobacco control state of Sweden
Therefore hugely important to legislate harm already in January 2016
Check it out below!