State of the evidence in Swedish Tobacco Control 2016

Morning all!

There is currently a furious back and forth in commentary regarding Tobacco Control, Tobacco Harm Reduction, and Tobacco Companies, following an Op-Ed letter in the NEJM (New England Journal of Medicine)

This series of communications (by no means finished) is hugely important in light of Sweden, without any credible evidence, imposing even harsher regulations on the lifesaving product snus earlier in 2016.

This is quite insane and totally counter to even the most basic notions of evidence based policy. To the best of Swedish knowledge, and using the best currently available statistical methods, 50% of total tobacco sales in Sweden is combustible tobacco and causes >98% of tobacco related disease; whereas the other 50% is sold in food grade non combustible format and accounts for <2% (in all likelihood the real burden is around 0,1%) of total disease and mortality burden in Sweden.

This is a bit of a read, and you need to follow it through, but more than well worth the time it will take, all credits to the NEJM from which these open source communications are taken with gratitude.

This is how it goes: 1st (top) is the article that started the debate. Then come 2 commentaries from McKee and also Myers from Tobacco Free Kids. After that comes the reply to them from the authors of the original article. In support of the original article and in scathing critique of the critique made by McKee there is then a series of comments made on-line in the commentaries section of NEJM, this is where the real fun starts.

This debate is totally unthinkable in Sweden, in Sweden being a scientist and pro “snus” (the food grade smokeless stuff that makes up 50% of total tobacco sales in the entire country) is by definition being a Tobacco Industry lackey and in most cases a total career suicide.

Peer pressure and organized institutional denial is so great in Sweden, to save face, that challenging the current dogma will get you ostracized, your funding will get pulled, career advancement totally out of the question and job severance a quite real likelihood, probably without even putting a dent in the armor of Tobacco Harm Reduction denial dogma.

This of course is not a very attractive option, despite the chance to be a part of saving hundreds of million smokers from an early grave, so there are not many who are willing to pick up the gauntlet.

Why the title choice? Because the only relevant scientific discussion that could be utilized to actually achieve evidence based policy in Sweden, is from outside Sweden, and disqualified in Sweden.

So officially the state of evidence in Sweden is ZERO


First, here is the actual article by Sharon, Green, Bayer and Fairchild (Mailman School of Public Health, Columbia University, New York), and also an audio interview (well worth 10 minutes of your time) with Amy Fairchild on August 4th 2016

Evidence, Policy, and E-Cigarettes — Will England Reframe the Debate?

Sharon H. Green, M.P.H., Ronald Bayer, Ph.D., and Amy L. Fairchild, Ph.D., M.P.H.

N Engl J Med 2016; 374:1301-1303April 7, 2016DOI: 10.1056/NEJMp1601154

Audio Interview

Interview with Dr. Amy Fairchild on public health recommendations regarding electronic cigarettes in England and the United States.

Interview with Dr. Amy Fairchild on public health recommendations regarding electronic cigarettes in England and the United States. (10:53)

Tobacco-control advocates have been embroiled in a multiyear controversy over whether electronic cigarettes threaten the goal of further reducing tobacco smoking or offer the possibility of minimizing harm for people who cannot or will not quit smoking conventional cigarettes. England and the United States have now staked out very different positions.

The international landscape was dramatically reshaped in August 2015, when Public Health England (PHE), an agency of England’s Department of Health, released a groundbreaking report, “E-cigarettes: an evidence update.” With its claim that e-cigarettes are 95% less harmful than combustible cigarettes, the report attracted headlines internationally. It recommended that smokers who cannot or will not quit smoking tobacco try e-cigarettes and expressed great concern that the public perceived the two products as posing equal risks. Strikingly, the report underscored e-cigarettes’ potential to address the challenge of health inequalities, a central mission of PHE, stating that these devices “potentially offer a wide reach, low-cost intervention to reduce smoking and improve health in these more deprived groups in society where smoking is elevated.”1

The report — written by tobacco-addiction researcher Ann McNeill of King’s College London — reflected the position on e-cigarettes that had been agreed to by the U.K. public health community. Yet the editors of the Lancet asserted that though PHE claims to protect the nation’s health and well-being, it has failed to do so with this report. Two public health scholars writing in the BMJ also denounced the report, seizing on the methodologic limitations of one of the many studies on which the evidence review had relied, underlining the potential conflicts of interests acknowledged in the paper, and roundly condemning PHE for failing to meet basic evidentiary standards. Invoking the precautionary principle, the authors asserted that e-cigarette proponents bore the burden of proving that these products are not harmful. In contrast, 12 prominent U.K. public health organizations, including Cancer Research U.K. and the British Lung Foundation, defended PHE. Their joint press release underscored a public health responsibility to encourage smokers to switch to e-cigarettes, perhaps with the help of local smoking-cessation programs.

As dramatic as the report’s recommendations appear to be, they built on the United Kingdom’s long-standing commitment to harm reduction. In 1926, the Ministry of Health’s Rolleston Committee concluded that drug addiction was an illness that should be treated by physicians, sometimes with a minimal dose of drugs in order to prevent withdrawal symptoms. When AIDS came to the United Kingdom in the 1980s, the first government report on human immunodeficiency virus (HIV) infection among injection-drug users encouraged safer drug practices. Meanwhile, the United States took a prohibitionist position. Tight narcotic regulation and refusal to provide narcotics to addicts as treatment or maintenance defined the U.S. posture for decades.

Application of harm-reduction principles to tobacco products debuted in England in the 1970s, at the Institute of Psychiatry of the Maudsley Hospital. In 1976, Michael Russell, pioneer of effective nicotine-cessation treatments, famously wrote that “People smoke for nicotine but they die from the tar,”2 suggesting that one could satisfy a nicotine craving without risking the harms caused by smoking. Professional medical bodies in the United Kingdom endorsed a harm-reduction perspective. A 2007 report by the Tobacco Advisory Group of the Royal College of Physicians made the case that strategies to protect smokers were key, since nicotine addiction is difficult to overcome and millions of people fail to quit. That report argued “that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved.”3

Even before e-cigarettes became widely available, the venerable and influential antitobacco organization Action on Smoking and Health (ASH) embraced the development of nicotine products that could rival the nicotine-delivery power of combustible cigarettes. Fiercely opposed to the tobacco industry, ASH had for decades called for increasingly stringent policies to reduce the prevalence of tobacco smoking by imposing higher taxes, banning advertisements, and setting strict limits on smoking in enclosed settings. In 2014, an ASH review of the evidence concluded that fears of a “gateway effect” were unsubstantiated and that e-cigarettes were being used largely by current or former cigarette smokers. Because it found little evidence that nonsmoking bystanders could be harmed by the vapor from e-cigarettes, ASH opposed inclusion of e-cigarettes in public smoke-free laws. Reinforcing his organization’s commitment to harm reduction and the primary goal of assisting smokers who could not or would not give up cigarettes, ASH’s chairman, John Moxham, said, “It would be a public health tragedy if smokers were discouraged from switching to electronic cigarettes and vapers were encouraged to go back to smoking because they don’t understand that vaping is a lot less harmful than smoking. That really would cost lives.”4 Not surprisingly, ASH applauded the findings of the PHE report.

The dominant policy perspective in the United States serves as a foil to the one embraced in England. The Campaign for Tobacco-Free Kids — ASH’s U.S. equivalent and a powerful voice in anti-tobacco advocacy — has been unequivocal in its denunciations of e-cigarettes. Similarly, the Centers for Disease Control and Prevention hosted a Public Health Grand Rounds on e-cigarettes in which all five speakers focused on the possible health risks associated with e-cigarette use. None acknowledged a potential role for e-cigarettes in reducing the tobacco burden in marginalized populations or reducing health disparities. Given the tight focus on potential risks to children and nonsmokers, e-cigarettes were out of the question. But one powerful voice for enhanced tobacco control in the United States did support the PHE report. In December 2015, the Truth Initiative (formerly the American Legacy Foundation) declared in an organizational position paper, “If prudently regulated, we believe ENDS [electronic nicotine delivery systems] hold promise as one means to move smokers to a less harmful product and reduce the devastating death and disease burden caused by combustible tobacco products.”5

What distinguishes the harm-reduction approach taken in the PHE report from the more absolutist approach adopted by U.S. policymakers today is a matter of focus. In England, where leading medical organizations regard nicotine alone as relatively benign, the pressing need to reduce the risks for current smokers frames the debate. The overwhelming focus in the United States is abstinence. It is in this broader context that the focus on children and nonsmokers must be viewed.

Will England change the international conversation about e-cigarettes? The answer will depend, in part, on what the evolving evidence suggests, and it may take years before the answers are definitive. In the end, the sorts of policies that are implemented will depend on whether whoever dominates the debate views harm reduction as opportunity or anathema.

Here are the replies to the Editor of NEJM regarding the actual subject matter


Evidence, Policy, and E-Cigarettes

N Engl J Med 2016; 375:e6August 4, 2016DOI: 10.1056/NEJMc1606395

To the Editor:

In their Perspective article in the April 7 issue,1 Green et al. argue that the English approach to e-cigarettes could reframe the debate on these products. They cite our article,2 implying that we were concerned about only one of the many studies in the Public Health England (PHE) review. That study was only one of our concerns, being the only source for the widely cited “95% safer” claim, especially given questions about conflicts of interest.3 We also discussed other evidence, some not quoted in the review, that raised serious questions about the safety of these products.4 Green et al. disregard the fact that harm reduction is only one element of a comprehensive drug strategy that, as in the successful Australian model, also encompasses reduction of demand and supply. It is misleading to suggest that there is a consensus on e-cigarettes in England, given that many members of the health community have continuing reservations.5 If we are to reframe the debate, maybe we should instead look to Australia, where adult smoking rates are now under 13%, without e-cigarettes.


Martin McKee, M.D., D.Sc.
London School of Hygiene and Tropical Medicine, London, United Kingdom

Dr. McKee reports that he chaired the Global Health Advisory Committee of the Open Society Foundations, which support and fund narcotics harm reduction. No other potential conflict of interest relevant to this letter was reported.

5 References

    1. 1

      Green SHBayer RFairchild AL. Evidence, policy, and e-cigarettes — will England reframe the debate? N Engl J Med 2016;374:1301-1303
      Free Full Text | Web of Science | Medline

    1. 2

      McKee MCapewell S. Evidence about electronic cigarettes: a foundation built on rock or sand? BMJ 2015;351:h4863-h4863
      CrossRef | Web of Science | Medline

    1. 3

      Gornall J. Public Health England’s troubled trail. BMJ 2015;351:h5826-h5826
      CrossRef | Web of Science | Medline

    1. 4

      Pisinger CDøssing M. A systematic review of health effects of electronic cigarettes. Prev Med 2014;69:248-260
      CrossRef | Web of Science | Medline

  1. 5

    British Medical Association. E-cigarettes. June 30, 2016 (

To the Editor:

Green, Bayer, and Fairchild misrepresent the position of the Campaign for Tobacco-Free Kids on e-cigarettes. From the beginning, our organization has called for the Food and Drug Administration (FDA) to regulate e-cigarettes. We have repeatedly stated that it is possible that e-cigarettes could benefit public health if they are properly regulated, shown to be effective at helping smokers quit smoking regular cigarettes completely, and responsibly marketed to smokers who cannot or will not otherwise quit.1,2 However, we have also raised legitimate concerns about the large and rapid increase in the use of e-cigarettes by young people in the United States and the irresponsible marketing of these products with the use of tactics similar to those long used to make regular cigarettes appealing to children.3 It is not by any definition “absolutist” to call for FDA regulation of e-cigarettes. Effective regulation by the FDA is critical to minimizing the risks posed by e-cigarettes and maximizing the potential benefits.


Matthew L. Myers, J.D.
Campaign for Tobacco-Free Kids, Washington, DC

No potential conflict of interest relevant to this letter was reported.

3 References

    1. 1

      Campaign for Tobacco-Free Kids. Comments submitted to the Food and Drug Administration on Docket No. FDA -2014-N-0189, RIN 0910-AG38, Proposed Rule on Deeming Tobacco Products to be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Tobacco Control Act; Regulations on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products. August 8, 2014 (

    1. 2

      Campaign for Tobacco-Free Kids. Comments submitted to the Food and Drug Administration on Docket No. FDA-2014-N-1936: Electronic Cigarettes and the Public Health Workshop. July 2, 2015 (

  1. 3

    Myers ML. Testimony to the Senate Committee on Commerce, Science, and Transportation. June 18, 2014 (


Author replies to the critique by McKee and Myers

The authors reply: We agree with Myers regarding the need to regulate electronic cigarettes sensibly to protect public health. Rules and policies should encourage smokers to switch to lower-risk tobacco products while also preventing nonsmokers, particularly young people, from picking up these devices. Nevertheless, our intention was to contrast the broad public stances toward e-cigarettes held by major antitobacco organizations in the United Kingdom and the United States. In the United States, many advocacy organizations claim to support tobacco harm reduction but effectively endorse prohibition by regulation. Although Myers and the Campaign for Tobacco-Free Kids may believe in the potential for e-cigarettes to benefit public health if regulated properly, their messaging does not support the use of e-cigarettes for harm reduction in the ways that the U.K. Action on Smoking and Health (ASH) does. The Campaign focuses primarily on the prevention of hypothetical risks to nonsmoking children, whereas ASH’s emphasis is on improving the health of smokers who cannot or will not quit smoking cigarettes, which kill half of all long-term users, who lose more than 20 years of life, on average.

In response to McKee: we did not suggest that harm reduction is the only strategy to combat tobacco. Two of us (Bayer and Fairchild) have written extensively on laws, taxes, and campaigns to reduce the burden of tobacco. The focus in our recent article was on tobacco harm reduction, which should, of course, be implemented as part of a comprehensive drug strategy. McKee is correct in pointing out that there is not complete consensus in the United Kingdom regarding e-cigarettes, as we noted in our article. But what we underscored and what makes the United Kingdom exceptional is that many leading organizations support e-cigarettes for harm reduction. In fact, 12 prominent British organizations signed a press release supporting the PHE report. These organizations included the British Lung Foundation, Cancer Research UK, Faculty of Public Health, and the Royal College of Physicians.1

Sharon H. Green, M.P.H.
Ronald Bayer, Ph.D.
Amy L. Fairchild, Ph.D., M.P.H.
Columbia University Mailman School of Public Health, New York, NY

Since publication of their article, the authors report no further potential conflict of interest.

1 Reference

  1. 1

    Public Health England. E-cigarettes: an emerging public health consensus. September 15, 2015 (


Here begins the flurry of online commentary

Here are the teams playing (though playing is not an adequate term since we are quite literally talking about hundreds of millions smoker lives cut short by non availability of effective harm reduction means)

Pro Tobacco Harm Reduction (Bates and Stimson)

Anti Tobacco Harm Reduction (McKee, Chapman, Myers, Daube)

Clive Bates2016 Aug 20 11:09 a.m. (4 days ago)edited 1 of 1 people found this helpful

The author, Martin McKee, makes no less than five assertions in this short letter that demand correction:

First, that there was only one source for the claim that e-cigarettes are “95% safer” than smoking. In fact, this claim does not rely on a single source but is the consensus view of Public Health England’s expert reviewers [1] and a close variation on this claim is the consensus view of the Tobacco Advisory Group of the Royal College of Physicians and is endorsed by the College [2]:

Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure. (Section 5.5 page 87)

Second, that PHE’s work was in some way compromised by McKee’s “concerns about conflicts of interest“. To support this largely self-referential claim, he cites a piece of very poor journalism in which every accusation was denied or refuted by all involved. Please see Gornall J, 2015 including my PuBMed Commons critique of this article and a more detailed critique on my blog [3].

Third, that “other evidence, some not quoted in the review, raised serious questions about the safety of these products“. The citation for this assertion is Pisinger C, 2014. This review does not, in fact, raise any credible questions about the safety of these products, and suffered numerous basic methodological failings. For this reason, it was reviewed but then ignored in the Royal College of Physicians’ assessment of e-cigarette risk [2 – page 79]. Please see the PubMed Commons critiques of this paper [4].

Fourth, that adult smoking prevalence in Australia is “below 13%, without e-cigarettes”. Both parts of this claim are wrong. The latest official data shows an adult smoking prevalence of 16.0% in Australia [5]. No citation was provided by the author for his claim. E-cigarettes are widely used in Australia, despite a ban on sales of nicotine liquids. Australians purchase nicotine-based liquids internationally over the internet or buy on a thriving black market that has been created by Australia’s wholly unjustified de facto prohibition.

Fifth, that we “should look to Australia” for tobacco policy inspiration. We certainly should not. Australia has a disturbingly unethical policy of allowing cigarettes to be widely available for sale but tries to deny its 2.8 million smokers access to much safer products by banning nicotine-based e-cigarettes. These options have proved extremely popular and beneficial for millions of smokers in Europe and the United States trying to manage their own risks and health outcomes. Further, the author should consider the harms that arise from Australia’s anti-smoking policies in their own right, such as high and regressive taxation and stigma that arises from its campaigns to denormalise smoking.

If the author wishes to find a model country, he need not travel as far as Australia. Sweden had a smoking prevalence of 11% in 2015 – an extreme outlier in the European Union, which averages 26% prevalence on the measure used in the only consistent pan-European survey [6]. The primary reason for Sweden’s very low smoking prevalence is the use of alternative forms of nicotine (primarily snus, a smokeless tobacco) which pose minimal risks to health and have over time substituted for smoking. This exactly what we might expect from e-cigarettes and, given the recent sharp falls in adult and youth smoking in both the UK and the US, this does seem likely. Going with grain of consumers’ preferences represents a more humane way to address the risks of smoking than the battery of punitive and coercive policies favoured in Australia.

Though not an expert in nicotine policy or science, the author is a prolific commentator on the e-cigarette controversy. If he wishes to raise his game, he should start by reading an extensive critique of his own article in the BMJ (McKee M, 2015), which is at once devastating, educational, and entertaining [7].


[1] McNeill A. Hajek P. Underpinning evidence for the estimate that e-cigarette use is around 95% safer than smoking: authors’ note, 27 August 2015 [link]

[2] Royal College of Physicians (London) Nicotine without smoke: tobacco harm reduction 28 April 2016 [link]

[3] Bates C. Smears or science? The BMJ attack on Public Health England and its e-cigarettes evidence review, November 2015 [link]

[4] Pisinger C, 2014 Bates C. comment [here] and Zvi Herzig [here]

[5] Australian Bureau of Statistics, National Health Survey: First Results, 2014-15. Table 9.3, 8 December 2015 [link to data]

[6] European Commission, Special Eurobarometer 429, Attitudes of Europeans towards tobacco, May 2015 [link] – see page 11.

[7] Herzig Z. Response to McKee and Capewell, 9 February 2016 [link]

Competing interests: I am a longstanding advocate for ‘harm reduction’ approaches to public health. I was director of Action on Smoking and Health UK from 1997-2003. I have no competing interests with respect to any of the relevant industries.


  • Gerry Stimson2016 Aug 21 3:51 p.m. (3 days ago)

    Clive Bates (below) identifies five assertions by Martin McKee that need correction: there are two more, making seven in McKee’s eleven lined letter.

    First, McKee states that ‘It is misleading to suggest that there is a consensus on e-cigarettes in England, given that many members of the health community have continuing reservations’ and quotes one short BMA statement that calls for medical regulation of e-cigarettes.

    He ignores the ‘public health consensus statement’ from English public health, medical, cancer and tobacco control organisations that supports e-cigarettes for quitting smoking. The consensus statement says that ‘We all agree that e-cigarettes are significantly less harmful than smoking.’ [1, 2]. The first edition of this statement [1] explicitly challenges McKee’s position on the evidence. The consensus statement is endorsed by Public Health England, Action on Smoking and Health, the Association of Directors of Public Health, the British Lung Foundation, Cancer Research UK, the Faculty of Public Health, Fresh North East, Healthier Futures, Public Health Action, the Royal College of Physicians, the Royal Society for Public Health, the UK Centre for Tobacco and Alcohol Studies and the UK Health Forum. McKee and the BMA are minority outliers in England and the UK.

    The PHE report on e-cigarettes faced a backlash but this was from a few public health leaders including McKee who organised a behind-the-scenes campaign against the report including a critical editorial and comment in the Lancet, and an editorial in the BMJ backed up by a media campaign hostile to PHE. Emails revealed as a result of a Freedom of Information request show that this backlash was orchestrated by McKee and a handful of public health experts [3, 4].

    Second, McKee misrepresents and misunderstands drugs harm reduction. He cites Australia, and it was indeed in Australia (as in the UK) that the public health successes in preventing the spread of HIV infection and other adverse aspects of drug use were driven by harm reduction – including engaging with drug users, outreach to drug users, destigmatisation, provision of sterile needles and syringes, and methadone [5, 6, 7]. Drugs harm reduction was a public health success [4, 6]. The UK and other countries that implemented harm reduction avoided a major epidemic of drug related HIV infection of the sort that has been experienced in many countries. Drugs harm reduction was implemented despite drugs demand and supply and reduction measures, not as McKee asserts because it was part of a combined strategy including supply demand and supply reduction. McKee’s position is out of step with the Open Society Institute, of which he chairs the Global Health Advisory Committee; OSI has resourced drugs harm reduction and campaigns against the criminalisation of drugs ie those demand and supply reduction measures that maximise harm.

    1 Public health England (2015) E-cigarettes: a developing public health consensus.

    2 Public health England (2016) E-cigarettes: a developing public health consensus.

    3 Puddlecote D, (2016/) Correspondence between McKee and Davies Aug 15 to Oct 15. Accessed 07 03 2016

    4 Stimson G V (2016) A tale of two epidemics: drugs harm reduction and tobacco harm reduction, Drugs and Alcohol Today, 16, 3 2016, 1-9.

    5 Berridge V (1996) AIDS in the UK: The Making of Policy, 1981-1994. Oxford University Press.

    6 Stimson G V (1995) AIDS and injecting drug use in the United Kingdom, 1988-1993: the policy response and the prevention of the epidemic. Social Science and Medicine, 41,5, 699-716

    7 Wodak A, (2016) Hysteria about drugs and harm minimisation. It’s always the same old story.

Simon Chapman2016 Aug 21 9:05 p.m. (3 days ago)

Clive Bates’ efforts to correct points made in Martin McKee’s letter in turn require correction and comment. Bates disputes that there was not a single source for the claim that e-cigarettes are “95% safer” than smoking (in fact Public Health England stated “95% less harmful” [1], a critical difference). Bates cites two references in support of his claim, but both of these are nothing but secondary references, with both citing the same Nutt et al [2] 95% less harmful estimate as their primary source.

Two toxicologists have written an excoriating critique of the provenance of the “95% less harmful” statement, describing its endorsement as “reckless”[3] and nothing but the consensus of the opinions of a carefully hand-picked group. The 95% estimate remains little more than a factoid – a piece of questionable information that is reported and repeated so often that it becomes accepted as fact.

We will not have an evidence-based comparison of harm until we have cohort data in the decades to come comparing mortality and morbidity outcomes from exclusive smokers versus exclusive vapers and dual users. This was how our knowledge eventually emerged of the failure other mass efforts at tobacco harm reduction: cigarette filters and the misleading lights and milds fiasco.

Bates challenges McKee’s statement that Australian smoking prevalence is “below 13%” and cites Australian Bureau of Statistics (ABS) data from 2014-15 derived from a household survey of 14,700 dwellings that shows 16% of those aged 18+ were “current” smokers (14.5% smoking daily). McKee was almost certainly referring to 2013 data from the Australian Institute of Health and Welfare’s (AIHW) ongoing national surveys based on interviews with some 28,000 respondents which showed 12.8% of age 14+ Australians smoked daily, with another 2.2% smoking less than daily[4]. The next AIHW survey will report in 2017 and with the impact of plain packaging, several 12.5% tobacco tax increases, on-going tobacco control campaigning and a downward historical trend away from smoking, there are strong expectations that the 2017 prevalence will be even lower.

Bates cites a 2015 report saying that Sweden has 11% smoking prevalence. This figure is almost certainly daily smoking prevalence data, not total smoking prevalence that Bates insists is the relevant figure that should be cited for Australia. If so, the comparable figure for Sweden should also be used. In 2012 the Swedish Ministry of Health reported to the WHO that 22% of Swedish people aged 16-84 currently smoked (11% daily and 11% less than daily) [5]. It is not credible that Sweden could have halved its smoking prevalence in three years.

Meanwhile, England with current smoking prevalence in 2015 of 18.2% in July 2016 [6 – slide 1] trails Australia, regardless of whether the ABS or AIHW data are used. Also, the proportion of English smokers who smoked in the last year and who tried to stop smoking is currently the lowest recorded in England since 2007 [6 slide 4].

Bates says that the UK and the USA where e-ecigarette use is widespread have seen “recent sharp falls” in smoking prevalence. In fact in smoking prevalence has been falling in both nations for many years prior to the advent of e-cigarettes, as it has in Australia where e-cigarettes are seldom seen. Disturbingly in the USA, the decline in youth smoking has come to a halt after 2014 [7], following continuous falls for at least a decade – well before e-cigarette use became popular. The spectacular increase in e-cigarette use in youth particularly between 2013-2015 (see Figure 1 in reference 7] was either coincident or possibly partly responsible with that halting.

Finally Bates makes gratuitous, unreferenced remarks about “harms” arising from Australia’s tobacco tax policy and “campaigns to denormalise smoking”. There are no policies or campaigns to denormalise smoking in Australian that are not also in place in the UK or the USA, as well as many other nations. When Bates was director at ASH he vigourously campaigned for tobacco taxes to be high and to keep on increasing [8]. His current views make an interesting contrast with even the CEO of British American Tobacco Australia who agrees that tax has had a major impact on reducing smoking, telling an Australian parliamentary committee in 2011 “We understand that the price going up when the excise goes up reduces consumption. We saw that last year very effectively with the increase in excise. There was a 25 per cent increase in the excise and we saw the volumes go down by about 10.2 per cent; there was about a 10.2 per cent reduction in the industry last year in Australia.” [9].


1 Public Health England. E-cigarettes: a new foundation for evidence-based policy and practice. Aug 2015.

2 Nutt DJ et al. Estimating the harms of nicotine-containing products using the MCDA approach. Eur Addict Res 2014;20:218-25.

3 Combes RD, Balls M. On the safety of e-cigarettes.: “I can resists anything except temptation.” ATLA 2015;42:417-25.

4 Australian Institute of Health and Welfare. National Drug Household Survey. 2014 data and references.

5 Swedish Ministry for Health and Social Affairs. Reporting instrument of the WHO Framework Convention on Tobacco Control 2012 (13 April)

6 Smoking in England. Top line findings STS140721 5 Aug 2016 1)

7 Singh T et al. Tobacco use among middle and high school students — United States, 2011–2015. MMWR April 15, 2016 / 65(14);361–367

8 Bates C Why tobacco taxes should be high and continue to increase. 1999 (February)

9 The Treasury. Post-implementation review: 25 per cent tobacco excise increase. Commonwealth of Australia 2013; Feb. p15

  • Clive Bates2016 Aug 22 02:45 a.m. (2 days ago)edited 1 of 1 people found this helpful

    Some responses to Professor Simon Chapman:

    1. Professor Chapman criticises the Public Health England and Royal College of Physicians consensus on the relative risk of smoking and e-cigarette use by referring to a comment piece Combes RD, 2015 in the journal Alternatives to Laboratory Animals. The piece is written by a commentator who’s affiliation is an animal welfare rights campaign (FRAME), for which ATLA is the house journal, and an independent consultant. How these two came to be writing about e-cigarettes at all is not stated, but this is less important than the fact that their commentary provides little of substance to challenge the robust expert-based PHE and RCP analysis, and it provides even less to justify the colourful dismissive pull-out quotes chosen by Professor Chapman. Even though the work can be dismissed on its merits, surely the authors should have disclosed that FRAME has pharmaceutical funders [Our supporters], including companies who make and sell medical smoking cessation products.
    2. Professor Chapman confirms my view that the appropriate statistic to use for comparing Australian prevalence of current smoking is 16.0 percent based on the Australian Bureau of Statistics, National Health Survey: First Results, 2014-15 (see table 9.3). This is the latest data on the prevalence of current adult smoking.
    3. Unless it’s to make the numbers look as low as possible, I am unsure why Professors Chapman and McKee choose to refer to a survey from 2013 or why Professor Chapman didn’t disclose in his response that he is citing a survey of drug use, including illicit drug use: [see AIHW, National Drug Strategy Household Survey detailed report 2013]. Surely a neutral investigator would be concerned that a state-run survey asking about illicit drug use might have a low response rate? And further, that non-responders would be more likely to be drug users, and hence also more likely to be smokers – so distorting the prevalence systematically downwards? In fact, the response rate in this survey is just 49.1% [Explanatory notes]. While this might be the best that can be done to understand illicit drug use, it is an unnecessarily unreliable way to gauge legal activity like smoking, especially as a more recent and more reliable survey is available.
    4. The figure of 11% given for smoking in Sweden is not ‘daily smoking’ as asserted by Professor Chapman. With just a little more research before rushing out his reply, Professor Chapman could have checked the source and link I provided. The question used is: “Regarding smoking cigarettes, cigarettes, cigars, cigarillos or a pipe, which of the following applies to you?” 11% of Swedes answer affirmatively to the response: “You currently smoke“.
    5. If we are comparing national statistics, it is true that measured smoking prevalence in Britain is a little higher than in the Australia – the latest Office for National Statistics data suggests 17.5 percent of adults age 16 and over were current smokers in 2015 (derived from its special survey of e-cigarette use: E-cigarette use in Great Britain 2015). So what? The two countries are very different both today and in where they have come from and many factors explain smoking prevalence – not just tobacco control policy. But if one is to insist on such comparisons, official data from the (until now) vape-friendly United States suggests that American current adult smoking prevalence, at 15.1 percent, is now below that of Australia [source: National Center for Health Statistics, National Health Interview Survey, 1997–2015, Sample Adult Core component. Figure 8.1. Prevalence of current cigarette smoking among adults aged 18 and over: United States, 1997–2015]
    6. Regressive taxes are harmful and so is stigmatisation – I shouldn’t need to reference that for anyone working in public health. Any thoughtful policy maker will not only try to design policies that achieve a primary objective (reduce the disease attributable to smoking) but also be mindful that the policies themselves can be a source of harm or damaging in some other way. Ignoring the consequences of tobacco policies on wider measures of wellbeing is something best left to fanatics. In public health terms, these consequences may be considered ‘a price worth paying’ to reduce smoking, but they create real harms for those who continue to smoke, and in my view, those promoting them have an ethical obligation to mitigate these wider harms to the extent possible.
    7. The approach, favoured by me and many others, of supporting (or in Australia’s case of not actively obstructing) ways in which smokers can more easily move from the most dangerous products to those likely to cause minimal risk has twin advantages:
    • (1) it helps to achieve the ultimate goal of reducing cancer, cardiovascular disease, and respiratory illnesses by improving the responsiveness of smokers to conventional tobacco control policy. It does this by removing the significant barrier of having to quit nicotine completely, something many cannot do easily or choose not to do.
    • (2) It does this in a way that goes with the grain of consumer preferences and meets people where they are. This is something for public health to rediscover – public health should be about ‘enabling’, not bullying or nannying, and go about its business with humility and empathy towards those it is trying to help.


  • Clive Bates2016 Aug 22 10:52 a.m. (2 days ago) 1 of 1 people found this helpful

    As an aside, it’s disappointing to see Professor Chapman spreading doubt about e-cigarettes with reference to the filters and ‘light and mild’ cigarette fiasco (see the 1999 report by Martin Jarvis and me on this fiasco). This ‘science-by-analogy’ fails because it misunderstands the nicotine-seeking behaviour that underpins both smoking and vaping.

    With light and mild cigarettes, health activists were fooled into believing that these cigarettes would much be less risky, even though they are no less risky. It would be wrong to compound this error by implying that e-cigarettes are not much less risky, even though they are sure to be.

    The underlying reason for both errors is the same – nicotine users seek a roughly fixed dose of nicotine (a well-understood process, known as titration). If a vaper can obtain their desired nicotine dose without exposure to cigarette smoke toxins, then they will not suffer the smoking-related harms. With light and mild cigarettes, both nicotine and toxins were diluted equally with air to fool smoking machines. However, human smokers adjusted their behaviour to get the desired dose of nicotine and so got almost the same exposures to toxins. This is another well-understood process known as ‘compensation’. I am sure a global authority of Professor Chapman’s stature would be aware these mechanisms, so it is all the more perplexing that he should draw on this analogy in his campaign against e-cigarettes.

  • As part of his lengthy and personalised attacks on Martin McKee, Clive Bates argues that “we certainly should not” look to Australia for policy inspiration.

    This view, and some of his other comments, would have strong support from the global tobacco industry, which has ferociously opposed the evidence-based action to reduce smoking taken by successive Australian governments, and reports that we are “the darkest market in the world”. (1)

    No doubt Mr Bates will be able to discuss these issues further with tobacco industry leaders at the Global Tobacco & Nicotine Forum (“the annual industry summit”) in Brussels later this year, where as in previous years he is listed as a speaker.(2)

    References 1. Brisby D, Pramanik A, Matthews P, Kutz O, Kamaras A. Imperial Brands PLC Investor Day: Jun 8 2016. Transcript – Quality Growth: Returns and Growth – Markets that Matter [p.6] & Presentation Slides – Quality Growth: Returns and Growth – Markets that Matter .




  • Clive Bates2016 Aug 24 1:56 p.m. (11 hours ago) 1 of 1 people found this helpful

    In response to Professor Daube, I am pleased to have the opportunity to explain a different and less authoritarian approach to the public health challenges of smoking.

    1. But let me start with a misunderstanding. Professor Daube accuses me of a personal attack on Professor McKee. In fact, I made five specific substantive comments on Professor McKee’s short letter, to which Professor Stimson added a further two. These are corrections of fact and understanding, not a ‘personal attack’. It is important that academics understand and recognise this distinction.
    2. Professor Daube draws the reader’s attention to a link to an investor presentation by Imperial Tobacco. I am unsure what point he is trying to make. Nevertheless, the presentation paints a rosy picture of life in Australia for this tobacco company: it is “on track” (p6); it has “continued strong performance in Australia” (p15); in Australia it is “continuing to perform strongly – JPS equity driving share, revenue and profit growth” (p31). It may be a hard pill to swallow, but tobacco companies in Australia are very profitable indeed, in part because the tax regime allows them to raise underlying pre-tax prices easily. It’s a common error of activists to believe that harm to tobacco companies is a proxy for success in tobacco control (an idea sometimes known as ‘the scream test’. If it that was the case, the burgeoning profitability of tobacco companies would be a sign of utter failure in tobacco control [1].
    3. In any event, my concerns are not about the welfare of the tobacco industry in Australia or anywhere else. My concern, as I hope I made clear in my response to Professor Chapman, is the welfare of the 2.8 million Australians (16% adults) who continue to smoke despite Australia’s tobacco control efforts. For them, the serious health risks of smoking are compounded by some Australian tobacco control policies that are punitive (Australia is not alone in this) while denying them low-risk alternatives. All the harms caused by both smoking and anti-smoking policies can be mitigated and the benefits realised by making very low-risk alternatives to combustible cigarettes (for example, e-cigarettes or smokeless tobacco) available to smokers to purchase with their own money and of their own volition. Professor Daube apparently opposes this simple liberal idea.
    4. Professor Daube finishes his contribution with what I can only assume is an attempted smear in pointing out that I sometimes speak at conferences where the tobacco industry is present, as if this is, a priori, an immoral act. I speak at these events because I have an ambitious advocacy agenda about how these firms should evolve from being ‘merchants of death’ into supplying a low-risk recreational nicotine market, based on products that do not involve combustion of tobacco leaf, which the source of the disease burden. So I have a public health agenda – the formation of a market for nicotine that will not kill one billion users in the 21st Century, and that will perhaps avoid hundreds of millions of premature deaths [2]. There is a dispute about how to do this, and no doubt Professor Daube has ideas, but the policy proposals for the so-called ‘tobacco endgame’ advanced by tobacco control activists do not withstand even cursory scrutiny [3]. The preferred approach of advocates of ‘tobacco harm reduction’, among which I include myself, involves a fundamental technology transformation, a disruptive process that has started and is synergistic with well-founded tobacco control policies [4]. If, like me, you wish to see a market change fundamentally, then it makes sense to talk to and understand every significant actor in the market, rather than only those who’s convictions you already share.

    References & further reading

    [1] Bates C. Who or what is the World Health Organisation at war with? The Counterfactual, May 2016 [link].

    [2] Bates C. A billion lives? The Counterfactual, November 2015 [link] and Bates C. Are we in the endgame for smoking? The Counterfactual, February 2015 [link]

    [3] Bates C. The tobacco endgame: a critique of the policy ideas. The Counterfactual, March 2015 [link]

    [4] Bates C. A more credible endgame – creative destruction. The Counterfactual, March 2015 [link].

    As I think Professor Daube’s comment is laden with defamatory innuendo, let me repeat the disclosure statement from my initial posting:

    Competing interests: I am a longstanding advocate for ‘harm reduction’ approaches to public health. I was director of Action on Smoking and Health UK from 1997-2003. I have no competing interests with respect to any of the relevant industries.



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