Richard Smith: How public health moralists are promoting harm from tobacco and helping the tobacco industry

richard_smith_2014David Sweanor, a Canadian lawyer who has many times successfully sued the tobacco industry, believes that those who instinctively react against e-cigarettes on moral grounds are making a bad mistake. We all, he says, have the fast form of thinking that is often morally driven, but when it comes to ways of reducing harm from tobacco we need the slow thinking that is logical, scientific, and harder work. He made his case convincingly at a C3 Breakfast Seminar this week.

It’s important, he believes, to try and understand the tobacco industry as deeply as possible and misguided to caricature it as a monolithic empire of evil. There are companies who think differently, and people within companies—for example, scientists and marketeers—who have different views. Sweanor takes every opportunity to meet people from the industry, and some 25 years ago he met a toxicologist from a tobacco company. The toxicologist said how the company saw Sweanor as a leading enemy and credited him with a big contribution to reducing smoking rates in Canada. But, said the toxicologist, you know that if I gave you a dollar for every schizophrenic you’d stopped smoking you wouldn’t have enough to buy lunch.

Almost every schizophrenic smokes and smokes heavily, said Sweanor. It’s been estimated that people with serious mental health problems, including chronic depression, account for 10% of cigarette consumption in the US, which amounts to sales of $10 billion a year. These people are self-medicating: nicotine helps with information overload and improves attention.

High income countries have done well with reducing smoking prevalence, but it still runs at about 20% in Britain. And, argued, Sweanor, it’s probably higher. Prevalence is often measured by telephone surveys with very low response rates; and in Canada, multiplying the number of cigarettes smoked by the number of smokers accounts for only about half of cigarettes sold. But even if the prevalence is around 20% it still means that tobacco, with its high toxicity, is harming more people than other risk factors.

So there are group of people, those with severe mental health problems and other disadvantaged people, who continue to smoke, and, as Sweanor kept emphasising (and to my amazement my wife didn’t understand), the harm comes from sucking smoke into the lungs not from the nicotine; the problem is the dangerous delivery system. It thus makes huge sense to encourage a safer way for some people to access nicotine. It may even make sense to offer ways of accessing nicotine, perhaps through e-cigarettes, to some of these people who might not smoke.

Promoting e-cigarette use in people who will otherwise not stop smoking is analogous, argued Sweanor, to making cars safer. Total abstinence is an unachievable goal, and the whole concept of abstinence has been poisoned and given moral overtones by the American experience with Prohibition. (He presumably would argue the same for “prohibition” of currently illegal drugs but didn’t in the seminar.)

The immediate and unthinking negative reaction to the idea of promoting e-cigarettes for those unable to stop smoking—illustrated by a recent piece in The BMJ —is short sighted. Sweanor compared it to Britain’s red flag legislation of 1906 that said that anybody driving a car must have somebody walking in front of the car with a red flag, to warn of the danger. European Union restrictions on e-cigarettes may have the same effect.

The evidence is clear that e-cigarettes are much less harmful than cigarettes, and the evidence that use of e-cigarettes encourages smoking among the young is weak and unconvincing. Smokers are beginning to use e-cigarettes on a large scale in the US, and Britain is following.

One reason that people may switch is that they can save substantial sums of money. Sweanor told the story of his cleaner, a refugee from Bosnia, who smoked very heavily. He tried many ways to help her to stop, but they all failed until she tried e-cigarettes. Her expenditure fell from $80 a week on cigarettes (sometimes replacing food) to $25 every two weeks. One result was that she saved enough to return to Bosnia for the first time and see her mother just before she died.

So fast thinking moralisers may be preventing other benefits for those who cannot stop smoking. Even more ironically, they may be protecting the tobacco industry. Selling cigarettes is hugely profitable, much more so than selling e-cigarettes. Furthermore, nobody could start a new tobacco company, but entrepreneurs can develop e-cigarette companies—and have done so. Sweanor argues that tobacco companies are in the position of Kodak when digital photography emerged. Kodak was slow to adopt the new technology and went bust. Tobacco companies, which are currently more profitable than ever despite 40 years of anti-tobacco action, are uncertain of how to respond to the threat of e-cigarettes. Some are selling them—to avoid going the way of Kodak—but others may try to stop the trend to e-cigarettes.

The moralisers who react instinctively against e-cigarettes may not only be harming those who find it impossible to stop smoking but also helping tobacco companies.

Competing interest: RS is a trustee of C3 Collaborating for Health. On Saturday he will be participating in a discussion on e-cigarettes at the Battle of Ideas at the Barbican

Richard Smith was the editor of The BMJ until 2004. He is now chair of the board of trustees of icddr,b [formerly International Centre for Diarrhoeal Disease Research, Bangladesh], and chair of the board of Patients Know Best. He is also a trustee of C3 Collaborating for Health.

  • skoony

    Thanks for a well written article. I would like to emphasize the reduction in cost. When I smoked 2 packs a day it cost me 15 dollars a day. Not counting hardware my cost per day in e-juice is 40 cent or less per. That is 97.4% reduction in cost. That my dear friend’s is what 99.9% of what’s behind the anti e-cigarette rhetoric.

  • What those “moralizers” hate most is that someone somewhere may be enjoying themselves — they’re the modern-day Puritans with their holier-than-thou intolerance for anything except Their Own Way.

    Thanks to vaping, I’ve been smoke-free for nearly 15 months — that’s 1 yr + almost 3 months — but if I had not found vaping, I would most definitely still be smoking, and would be smoking until I died — I tried 4 times to quit, before e-cigarettes, and found only misery and failure, so I had quit quitting.

    When I started vaping, I had no idea that it might actually help me quit smoking and stay that way; I merely wanted some way of indulging my habit in my home instead of freezing to death on the front porch — but within a month of beginning to vape, I no longer smoked — without any of that misery and absolute psychosis that I experienced in my previous attempts.

    I think it is the lack of suffering that offends the moralists so extremely — how DARE we find something that offers us a free pass out of smoking, without any suffering required?! They just can’t stand the fact that we’re still enjoying something which their tiny puritanical minds dismiss as “evil” — while they’re sucking down coffee and cocktails by the gallon.

    I have no use for any moralist anywhere, and it would suit me just fine if we fired the entire lot of them into space. Nobody’s smoking out there.

  • Simon_Chapman

    Perhaps David Sweanor would like to explain (1) why the born again caring nice guys at Big Tobacco are still doing all they can to thwart effective tobacco control like tax increases, plain packs and graphic warnings if they see the future in ecigs (2) what he makes of the recent 12 month follow-up study by doyens McNeill & West which found ““Daily use of e-cigarettes while smoking appears to be associated with subsequent increases in rates of attempting to stop smoking and reducing smoking, but not with smoking cessation. Non-daily use of e-cigarettes while smoking does not appear to be
    associated with cessation attempts, cessation or reduced smoking.” (3) what he makes of English data that show that while ecigarette use has been rising, quit attempt rates have been falling among smokers and are now at their lowest level since 2007; and (4) why he makes statements that “almost every schizophrenic smokes” when evidence suggests otherwise. (

    The tobacco industry’s agenda is to see smokers smoke AND vape, not smoke OR vape and that’s precisely what is happening (see with nearly 90% of vapers also smoking. Australia has the lowest smoking prevalence of any nation (12,8% daily smoking) and we have negligible ecigarettes here.

  • Stan Shatenstein

    Simon Chapman makes the counter-argument impeccably, but I would add that
    David Sweanor’s car analogy is fatally flawed and underscores the moral weakness
    of his own case. Seatbelts, airbags and other safety features can be made
    mandatory, thus making driving safer in all vehicles. If e-cigarettes do not force conventional
    ones off the market, then the same dangers remain. This can only make the tobacco
    industry stronger as it gets more deeply involved in e-cigarettes and can subtly
    or openly promote them ‘for those times you can’t smoke’. And e-cigarette marketing can and does, intentionally or not, re-glamourise the act of smoking.

    There are arguments in favour of e-cigarettes, and there are, no doubt,
    individuals who have quit smoking by using them, but there are many caveats and
    risks associated w/e-cigs, as Chapman and many others have pointed out. What is
    particularly offensive in Sweanor’s argument is that legitimate, science-based
    objections constitute ‘moralising’, when they are nothing of the sort and, far
    worse, his ad hominem attack on those of us unconvinced about e-cigs as potentially “protecting the tobacco
    industry”. Using more polite language, Sweanor is saying we are either venal or stupid.
    We are not. We simply do not see e-cigarettes as a panacea for the tobacco
    epidemic and, more precisely, see more risks than benefits at a populational

  • Rojeans

    Simon Said.. “(3) what he makes of English data that show that while ecigarette use has been rising, quit attempt rates have been falling among smokers”
    Simply because e-cigarette users do not use stop smoking services. ie; they’re off the NHS / your radar Simon.

  • Rojeans

    Simply because e-cigarette users do not use stop smoking services. ie; they’re off the NHS / your radar Simon.

  • JonathanBagley

    Widespread vaping is fairly recent. When I switched just over three years ago, the vast majority of UK smokers knew little about it. It is no surprise to me that 80% of vapers might be dual users. Due to the steep increase in usage, many of those questioned will still be in their first year of vaping. I continued smoking a few cigarettes a week during my first year. They may be using not very effective cigalike devices, rather than the refillable tank devices (to be banned by the EU Tobacco Products Directive next May). They may smoke a few cigarettes while on holiday, as I do.

    What is important, is that hundreds of thousands of UK former smokers now smoke very few or zero cigarettes, and that when people are vaping, they are not smoking; and overall, since they require some fixed amount of nicotine, they are smoking less, and the harm due to smoking depends on amount smoked. That is why researchers use the term “pack years” in their research literature.

    Among males, Sweden has a lower smoking prevalence than Australia. This is due to the widespread use of the oral tobacco product, snus – bizarrely banned from sale in the rest of the EU. Sweden has the lowest male lung cancer incidence in the developed world – half that of the EU average – and a lower than EU average of cancers claimed by some to be associated with oral tobacco – for example, oral and pancreatic.

    Eliquid contains no tobacco products other than nicotine, which can also be extracted from tomato leaves and stalks. The effects of inhaling nicotine and propylene glycol have been thoroughly research – in the UK, nicotine inhalers have been classed as safe for long term use by 12 year olds. Vaping is even safer than snus.

    Hon Lik, the Chinese inventor of the modern ecig, should be awarded the Nobel Prize for medicine. His invention has prevented and will prevent hundreds of thousands of people contracting lung cancer.

  • Deb Downes

    Dear Simon, wrt your points:

    1. Because the “nice guys” @ BT are covering all their bases. As you well know, they’re parasites – they’ll keep producing cigarettes and buying vaping companies, whilst actively promoting regulations for ecigs that suit their business model, and not the best interests of the individuals who use any of their products. They are actively assisted in this process by various Public Health and Anti Tobacco organisations, who would also like to see vaping regulated in a manner which is much more onerous than the regulation of tobacco products. Therefore, we have this peculiar situation where PH and Anti Tobacco people are assisting the Tobacco Industry, to the detriment of a harm reduction strategy.

    2. People are using ecigs in an attempt to give up tobacco, which is difficult to do. I would have thought that increased rates of attempting to quit was not such a bad thing. Sadly, vapers are human beings, they’re not perfect, they may not succeed, but at least they’re trying. I’d like to know how it compares with using NRT. On a positive note, there was a substantial decrease in tobacco consumption, but I guess you weren’t interested in that.

    3. There’s a lot of positive information in that document, but perhaps that didn’t interest you. If you examine the conclusions, you will see that growth in ecig use has slowed. Looking at the timeframe, it pretty much coincides with the major misinformation campaign that has been conducted by public health, anti tobacco and medical organisations regarding ecigs. It’s been well noted that this campaign has worked, people are choosing to continue using tobacco. Oh, and the re-election of the current UK government probably hasn’t helped either. People are depressed and down trodden, not motivated to do anything.

    4. Citing yourself?

    “Conclusions: Studies reporting very high prevalence of smoking among people with schizophrenia are cited more often than those studies reporting a low prevalence, a result consistent with citation bias. This citation bias probably contributes to the misinformation available on the Internet, and may have adverse policy and clinical implications.”

    I’ve no doubt that there are exaggerations regarding the data in this area. However, if we’re talking about smoking, then the exaggerations are coming from your side of the fence – y’know, the people who want people to quit tobacco?

    You have been on a commendable campaign for many years regarding tobacco. Sadly, you have no understanding of the issues that a long term smoker faces wrt quitting. You know that NRT is a failure.

    Tobacco is facing it’s Kodak moment, if only we could just get on with making that happen!

  • Stuart Fagg

    Robert West has clarified that the graph showing 80-90% as being dual users also included those that have stopped smoking in the past year (as it also says at the bottom of the graph).

    The still smoking figure is significantly less.

    Regardless, dual use is recognised by NHS SSS as being an important & effective road to eventual cessation of smoking,

  • Jon

    Great post Andria!
    I think you’ve hit the proverbial nail squarely on the head there! 🙂

  • Glad you are on the subject of explanations. Sweden has had more than 10% male snus use for over 100 years, and yet to register one single documented fatality. Please enlighten us all by expertly explaining the below graphic.

  • David Dorn

    Shatenstein would do well to consider how “safe” seat belts and airbags have made driving. Checking the figures for admissions to hospitals following RTAs in the UK, he will not see a downturn since seat belts became mandatory. What he might see is a reduction in the severity of injuries and fatalities. He will also see that said reduction had begun well before the legislation as drivers and passengers had adopted their use voluntarily prior to their being forced to. In other words, the legislation made precisely no difference.

    The same is true of Ecigs – like seat belts, they are a harm reduction strategy. Had Shatenstien applied the same logic to seat belts as he does to Ecigs, how many more deaths would there have been on our roads? The tobacco companies must love both Shatenstien and Chapman – both are doing their work for them!

  • Angel Tibbs


  • Angel Tibbs

    I second the Nobel Prize for Hon Lik, and I really liked your post.

  • Stan Pijl

    Let me see if I can understand your logic; unless the reduced harm option is made mandatory, people seeking to use the reduced harm option must be forced to use the more dangerous option. The ethical and moral implication of this is staggering considering the vast difference in risk between e-cigs and tobacco cigs. Continuing on with your logic, if my government decided to eliminate all laws for mandatory seatbelt use, you would want all cars to then be required to have their seatbelts removed?

    You may be surprised to know that nicotine gum is marketed ‘for those times you can’t smoke’, as it is clearly understood that this type of use actually increases the chances of near-future success in quitting.

    I don’t think Mr. Sweanor would discount actual “legitimate, science-based objections”, the real issue is that no evidence exists to support these objections. Those who present these objections as if they were supported by evidence, despite being repeatedly shown the evidence is substantially stronger for the opposite conclusion are not interested in the truth. What other conclusion should we come to then?

  • Zvi Herzig

    1) Can you carefully look at the responses to Simon’s arguments and reconsider?

    2) Assuming that it was not possible to legislate seatbelts, airbags etc., wouldn’t they still have contributed more good than harm?

    3) You write:
    “If e-cigarettes do not force conventional
    ones off the market, then the same dangers remain. This can only make the tobacco industry stronger as it gets more deeply involved in e-cigarettes and can subtly
    or openly promote them ‘for those times you can’t smoke’.”

    Are you arguing that EC may not help reduce the smoking rate? If so, please explain why the available evidence is insufficient,

    4) You write, “And e-cigarette marketing can and does, intentionally or not, re-glamourise the act of smoking.”

    Is it a beneficial for a business when its competitor advertises? .There may be exceptions, but as a rule, no; the direct appeal of an ad is much more likely to influence than the indirect effects.

    Regardless, banning truthful cessation claims is certainly likely to increase the glamorous advertisements (because it would not be marketed for cessation).

    5) You write, “Sweanor is saying we are either venal or stupid.”
    Another possibility is that sometimes highly intelligent good people can be influenced by strong ideological emotions,

    Also, some of the most successful leaders of the tobacco control movement feel threatened that harm reduction may to overshadow much of their important accomplishments, This may lead to powerful emotional bias.

  • JonathanBagley

    Thank you Angel. I looked into the awarding of Nobel Prizes. Apparently there is no opportunity for lobbying. Potential recipients cannot be proposed. One can only hope that those with the power consider Hon Lik.

  • JonathanBagley

    If you looked at graphs of road traffic deaths in various countries, you would not be able to tell when, if ever, seat belt, breathalyser and air bag laws were introduced. In the UK, resistance to seat belts virtually stopped with the widespread fitting of inertia reels. Before that, they were inconvenient, uncomfortable and dirtied ones clothes. Nothing to do with a law.

  • Angel Tibbs

    If they honestly listen to PHE and M.O.V.E., maybe. Thanks.

  • David Sweanor

    It is good to see that this coverage of my talk last week has spurred some discussion. As it appears that the criticisms made and questions raised have been ably answered by others I will focus on other points.

    Not everyone opposed to innovative less hazardous alternatives to lethal cigarettes is a moralist, as there can certainly be other reasons to show opposition. Plus it is often hard to accept that a position is based on moralism or ideology rather than being purely rational.

    But an interesting test would be to look at other issues where one accepts that, as Allan Brandt states in his book ‘No Magic
    Bullet’ about venereal disease, there is a constant tension between those engaged in a moralist/behavioralist approach and those engaged in a pragmatic one. So I have found it useful to constantly ask myself if my stance on any issue has more in common with scientists or creationists; with pragmatic advocates on illicit drugs, sexual health, alcohol, etc. or folks like Wayne Wheeler, Nancy Reagan and the US Christian Right. As risk reduction is a key component of true public health efforts, failure to accept anything in that realm on any issue is a pretty good indication of failing a ‘duck’ test.

    But I think the issue here is much greater than a cultural anthropological examination of underlying moral psychological motivations. We have known for decades that people smoke for the nicotine but die from the smoke. We know that cigarettes can be replaced with massively less hazardous alternatives. We know that there are genetic and neuroscientific reasons for nicotine use and something in the range of one and a half billion people still having to get their nicotine through inhalation of the deadly products of combustion. But we have done very little to use these insights to save lives.

    As someone who has spent decades studying the cigarette trade and looking at the history of other innovative public health measures, I know there is now a potentially enormous existential threat to the cigarette companies. We currently have an incredible range of innovative technologies (available and in development) vying to grab part of the ripe-for-obsolescence $800 billion cigarette market – just as innovation is disrupting so many other markets. The question is whether we can channel this innovation in a way that delivers an enormous public health breakthrough. Or if instead we seek to simply try to stop innovation – a strategy with a very long history of exceedingly little ultimate success, and one that has the obvious downsides of protecting the cigarette trade and allowing those who do not focus primarily on health to set the agenda.

  • I think that your statements are as much “moralistic” as the ones you criticize as being moralistic. By making the debate a “moralistic” issue, you fail to recognize the importance of solid scientific data (or lack of it) as well as the potential public health harms of e-cigarettes, which are being sold by most companies for profits, appealing to youth, and not so much for potential health benefits.

    In the 1950s the cigarette industry introduced cigarette filters and convinced millions of smokers that they were safe. It turns out that filters are no safer than not having them, and even may have contributed to increased prevalence of adenocarcinoma, a now-common type of lung cancer.

    Claims of safety are not always correct, and experience and wisdom should tell us that proper regulation and scientific studies are needed. Products sold, in an unregulated way and particularly for profit, in 8000 flavours and containing nicotine, an addictive substance that can also cause direct harm itself, need to be regulated properly.

    If e-cigarettes can help some people quit smoking, let them be made available to those smokers in a regulated way, and not sold in shops to youth as if they were candy.

  • Alan Beard

    You labour under the misapprehension that tobacco co own a substantial proportion of the e-cigarette market
    Different markets around the World, but in the UK they own 20% of a declining ‘cigalike’ market,whereas the vastly more popular and effective ‘tank’ market is owned by independents(of the Tobacco Industry). This undoubtedly clouds your judgement and subsequent commentary that misses the point

  • OfJamaicensis

    “you fail to recognize the importance of solid scientific data (or lack of it)” … “and not sold in shops to youth as if they were candy.”
    So do we have any scientific data to suggest that the Vape Industry targets the youth?

  • Let the American Academy of Pediatrics respond to any criticism from those who support vaping and encouraging, with many flavors and addictive nicotine, e-cigarette use among children and youth.

  • The American Academy of Pediatrics will answer your criticism and support my view that e-cigarettes and the terrible way they are marketed, really as addicting nicotine-delivery systems, to appeal to kids, in flavours and styles that make the mind boggle. You may disagree with 60,000 pediatricians, but that is your right.

  • David S. Carter

    As well as promoting healthy behaviors to children and reducing exposure to adult’s smoking, the smoke free events will also help to reduce litter and reduce the chances of young children picking up and potentially eating cigarette butts that are toxic.

  • gotsteam


  • gotsteam

    “If e-cigarettes can help some people quit smoking, let them be made available to those smokers in a regulated way, and not sold in shops to youth as if they were candy.”

    You mean like they do in convenience stores selling regular cigarettes Frank?