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An Interview With David Sweanor on the E-Cigarette, Tobacco harm reduction, snus and other issues
Tuesday, December 22, 2009

David Sweanor has worked with numerous companies and organisations, including the International Union Against Cancer, World Health Organization, World Bank and the Pan American Health Organization, on the issue of tobacco harm reduction. He has received both international recognition and prestigious prizes for his work.

How did you get interested in the issue of Tobacco Harm Reduction?

I have been actively involved in tobacco and health policy issues since the beginning of the 1980s. During that time I have tried to apply the lessons from other successful public health campaigns. Any effort to reduce death, injury or disease entails some combination of four broad strategies:

1) Measures to prevent people from ever engaging in a risky behaviour
2) measures to get those engaging in the behaviour to cease engaging in it
3) efforts to prevent injury to third parties as a result of the behaviour
4) efforts to reduce the risks to those who will continue the behaviour.

By the early 1990s there was no doubt that the vast majority of the harm caused by smoking was from the method of nicotine delivery rather than from the nicotine itself. There would be a parallel problem if people got caffeine from smoking tea leaves rather than making an infusion of these leaves in hot water. At the same time the projections of future smoking rates was for increasing consumption despite global anti-tobacco policies, and there was increasing scientific understanding of the reasons people use nicotine. An 'abstinence-only' policy aimed at a nicotine-free world was simply unrealistic.

So certainly by the 1990's, and much earlier in the case of far-sighted researchers such as Michael Russell, it was clear that there were huge gains to be made from dealing with the delivery system. Oddly, though there had by that time been much focus on issues such as where the product could be used, how it was taxed, limits on advertising, controls on places of sale, packaging requirements, etc., there was little to nothing being done about the product itself.

What progress has been made since you got involved?

Short answer: Not enough.

Longer answer: There is now a much greater awareness that there is a very pronounced continuum of risk depending upon how nicotine is delivered. We are also seeing greater (though still poor) availability of medicinal forms of nicotine and a proliferation of new nicotine products. There is also no longer any scientific doubt that combustion-based products are massively more hazardous than non-combustion products such as Swedish snus. My experience is that as soon as someone grasps the concept of the continuum of risk and recognizes that all nicotine use is not going to end anytime soon, the pieces start coming together. This comes at a time that many countries are moving toward regulating tobacco products and discussing the need for some form of comprehensive regulatory oversight of the full range of nicotine products. Clearly, any rational health-focused regulation will demand that we deal with issues of differential risks.

I know that you don't necessarily agree with our theory that there is a conspiracy against alternative forms of smoking. Yet you have said Snus is a far safer alternative to smoking than cigarettes. How do you explain the reasons for illogical bans against alternative forms of tobacco such as in the European Union, where Snus has been banned but both cigarettes and more dangerous forms of chewing tobacco remain legal?

I think cigarettes have dominated the marketplace of most countries for so long that people have trouble even thinking of alternatives. Many of those who seek restrictions on non-combustion products, and certainly some of the companies selling them, see them as a way to perpetuate rather than replace cigarette smoking. When snus was positioned as a potential additional problem, rather than as a potential partial solution to a much bigger health problem, efforts to keep it off the market seemed logical.

We also have an issue with the tendency of our species to do something 'because we can' rather than to look at issues in a more comprehensive way that will better meet long term goals. It was possible to get laws banning a tobacco product that was not yet on the market, just as today it is possible to enforce existing drug laws to ban new recreational nicotine products. Had there been greater awareness of relative risks and a less risk-averse mentality snus could have been seen the way auto safety advocates saw Volvos – an agent of change for the marketplace.

What damage has been caused by the Snus ban?

I think the key thing is that we have lost a great chance to effectively show 'proof of concept' for the provision of less toxic alternatives to cigarettes. As soon as there is recognition that consumers can access nicotine without repetitious inhalation of tobacco smoke, and that some portion of current smokers find this to be an acceptable (even preferable) alternative to smoking, it causes a paradigm shift. If we get to the point of no longer seeing cigarettes as a 'nicotine maintenance monopoly' we could change the face of public health. If we recognize that the needs of smokers can be met in a way that does not necessarily result in the untimely death of roughly half of long term users maybe we can move society conceptually to the point that nicotine delivery can go through the same metamorphosis as we've seen with auto safety, telecommunications, sanitation, pharmaceuticals, food preparation standards, alcoholic beverages and a myriad of other goods and services. The market could be transformed (assuming an appropriate regulatory system) through a virtuous circle of increasing consumer awareness and ever-less-hazardous alternatives to cigarettes.

In addition the ban on products such as snus causes significant ethical and human rights problems. The idea of simply denying access to such a product to millions of smokers – people who are thus left using a massively more hazardous product – should be a great cause of concern. Misleading statements about the risks of products such as snus, especially those from major health organizations and government health departments, also run the risk of eroding consumer trust in public health authorities – a problem that ultimately impacts far more than issues of nicotine.

Do you see any parallels between Snus and the Electronic Cigarette, and the opposition against both of them?

Some part of the opposition to nicotine products comes from the same moral absolutism that we see in other abstinence-only efforts on issues concerning such things as alcohol and sexual activity. Actually, on a very wide range of issues there is a tension between those on a moralist/absolutist quest (usually tied to ideas on the perfectibility of mankind) and those on a pragmatic public health mission. It would wrong to characterize those on a moral quest as being public health advocates, and this is true whether looking at abstinence-only campaigns on sex, on alcohol, on illicit drugs or on nicotine. Campaigns based on making better people rather than making people better are driven by moral concerns rather than public health concerns.

You've stated that electronic cigarettes are not safe, but that they are a lot better than cigarettes. Just how unsafe are they?

After many tens of thousands of research papers we know what causes the illnesses associated with smoking. In short, 'it's the smoke, stupid'. Non-combustion products will vary in their risks, but everything we can see about the sort of product sold in the West (whether smokeless tobacco, electronic cigarettes or medicinal nicotine) tells us that cigarettes are orders of magnitude more hazardous.

As to 'not safe', we perhaps need elaboration. The point I try to make when faced with the 'it's not safe' canard is that nothing meets the criteria of being absolutely 'safe'. Everything has risks, so simply pointing out that something is 'not safe' shows a person to be either ignorant or disingenuous. The key issue in looking at safety is that it is a relative concept; we need to look at safety of any activity compared to some alternative. Rather than the unattainable standard of 'safe' we should be thinking in terms of 'safer'. Despite the risks associated with soccer, I would, for instance, prefer my children play soccer rather than play with live hand grenades.

You are a supporter of the electronic cigarette? Can you tell us why?

I am a supporter of less toxic alternative for smokers. Nicotine use should not come with a death sentence.

Ideally we need a nicotine regulatory authority that can facilitate efforts to get alternative products to smokers, accurately inform them of relative risks and move them as far as possible down the continuum of risk.

The nicotine market needs to experience a shake-up and the entrepreneurs who appear to be behind the e-cigarettes might be sufficiently risk-tolerant to cause it to happen. The issue needs to get on the public and political agenda, and we will not get the needed re-thinking of the whole nicotine market until this happens.

Opponents of the electronic cigarette have said that it could stop smokers from giving up, that is untested and untried and that claims that the electronic cigarette are healthier than normal cigarettes are unproven. How would you respond to these allegations?

There is no innovation that I am aware of that did not cause detractors to list various potential negative consequences were the product to be made available – even safety bicycles in the 1890s! But when the status quo is one that will, according to the WHO, result in a billion deaths this century surely we need more than a fear 'something bad might possibly happen' to reject an alternative to that status quo.

The obvious solution is to have a regulatory agency that facilitates getting the least hazardous products to consumers, with post-marketing surveillance to control any unintended negative consequences. It certainly would make much more sense than the current state of affairs where government agencies are banning products like snus and e-cigarettes, greatly constraining the potential market for medicinal nicotine, and thus protecting the cigarette cartel rather than the health of citizens.

If there is anyone who believes cigarettes are no more hazardous than e-cigarettes I'd recommend a remedial course in basic sciences. For anti-nicotine campaigners who say we need to wait for more research I would point out the way they are proving Nietzsche correct – we take on the attributes of our enemies. Cigarette companies spent decades making spurious claims that we need 'more research' before we could move on policy measures, despite the already-existing basis for informed policy measures. They provide very poor role models.

One criticism that has been levelled at the electronic cigarette is that we don't know the effect of heating up a nicotine vapour and inhaling it into the lungs. Is this a valid criticism?

We certainly know that inhaling a heated nicotine vapour into the lungs is one heck of a lot less hazardous than inhaling the same vapour along with the thousands of chemicals and dozens of known carcinogens that are inhaled when that vapour is delivered by smoking a cigarette. An investigation to determine if the non-smoke vapour is, say, 1/100 or 1/1,000 the risk of cigarette smoking might be a good thing. But if someone thinks cigarettes should not be challenged in the marketplace until we have such results I think they need to try thinking a little more deeply. They should also question whether they have undergone a Nietzsche-like transformation that is causing them to be sounding like a 1970s cigarette company executive.

How do you feel about the public health campaigners, via their campaign to ban electronic cigarettes, attempting to limit the choice of addicted smokers unable or unwilling to quit smoking to cigarettes and cigarettes alone?

I don't think public health campaigners do this. I think some people on a moralistic abstinence-only agenda take this position, just as some take the position that consumers of alcohol should have no alternative to products like Jamaican Jake or that no one should have access to birth control, or that heroin addicts should not be given clean needles. But those people are not public health campaigners.

At the same time, I think there are people who are legitimate public health campaigners who oppose products like e-cigarettes. This can be because they want all such products to come within a comprehensive regulatory framework for all medicinal and recreational nicotine products; one designed to help move smokers away from cigarettes. They fear that unregulated products could proliferate and create a huge 'snake oil' business. But I also think it is incumbent upon such people to be advocating for such a regulatory framework rather than just inadvertently protecting the cigarette business.

The issue of electronic cigarettes is up in the air at the moment. How do you see the future - will it follow Snus into oblivion or will it become the smoking method of the future?

I think we are in the early stages of a revolution on recreational nicotine delivery. Just as with the telecommunications revolution it is likely impossible at an early stage to know how it will change. But it is a safe bet that consumer interests and entrepreneurship will combine to cause fundamental change, as we are already seeing with the rapid growth of non-combustion tobacco products in places such as Norway and the United States and the much greater use of medicinal nicotine products for purposes other than near-immediate nicotine cessation. The winning products in this market transformation will likely be of a wide variety, given differing consumer preferences and the nature of dynamic markets. I personally think that some of the most successful products will likely help consumers wean themselves off nicotine over time. But hundreds of millions of smoking-caused deaths will be averted by greater consumer choice and a proliferation of products, untold billions of dollars will be made by the owners of the successful products, and innumerable jobs will be created as this market transforms. Seldom is there an offer to become a billionaire while saving millions of lives. I think there will be takers.

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