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.