Thursday, 10 December 2015

Do we really have a tobacco epidemic?

I don't believe I can even count the times I've read or heard about the tobacco epidemic and the worldwide tobacco problem since I started this blog and really got into keeping myself up to date on the vaping debate and harm reduction. Last week I wrote that Norwegian smoking prevalence is dropping faster than ever and the fact that it looks like Snus, and lately e-cigarettes, have been playing quite a big role in making this happen. Now, obviously, both Snus and e-cigarettes (can) contain nicotine, and Snus is even made from tobacco. Still I would argue that none of these are part of the problem, but rather part of the solution to the tobacco problem. So how can a tobacco product be the solution to the tobacco problem? I guess this very question is usually asked by "the other side", along with another question: How can we solve the nicotine addiction problem with nicotine? I bet most of you can answer that question, and I bet most will start out with something like this: "You see nicotine is not really the problem...". So what is the problem then? How many of you would answer "tobacco" to this last question? I'll have to admit I've answered that quite a few times.

Yesterday a commentary (in Norwegian) by Håkon Olav Leira was published in Tidsskriftet (Journal of the Norwegian Medical Association) titled "E-cigarettes - an important measure against harm from smoking". Being an MD, PhD, Post doctor and actually treating patients with smoking related issues on a daily basis means Leira knows what he's talking about. (Have a look at his public linkedin page if you're in doubt)
E-cigarettes can be a good alternative to regular cigarettes, which can save many years of life lost and money better spent elsewhere. Sadly, the minister of health and central health communities wants to restrict access.

I treat patients with severe smoking-related illness on a daily basis, provide advice on smoking cessation and reduction of cigarette consumption, and have been thrilled with the possibility of now being able to offer yet another means of smoking reduction, e-cigarettes. My impression from my own practice is that e-cigarettes and smokeless tobacco are more attractive to experienced smokers than patches and nicotine gum.

Therefore I'm puzzled by the significant resistance our Minister of Health, Public Health and experienced colleagues have shown towards legalizing e-cigarettes. Most recently in the discussion taking place in this journal this summer e-cigarettes was presented almost as a stimulus to continued smoking. The fight against tobacco is in this discussion turned into a fight against all nicotine, where we run the risk of winning the battle but lose the war.
The discussion he's talking about is the discussion that followed Sanner and Grimsruds attack on e-cigarettes, where they were challenged over and over again to produce any evidence of nicotine harm and the gateway theory, but in my opinion failed horribly. It all ended with them saying that it's not possible to prove nicotine is addictive because addiction is a complex problem. Then they accuse me of conflicts of interest because I have some ads on my blog. In the same comment, they state that the fact that the authors of the only source they point to in this question was kicked off the FDA TPSAC by a federal judge due to severe conflicts of interest... does not change anything at all. Go figure.

Anyway, back to Leira's article. After telling us that the Directorate of health estimates that smoking causes 8000 deaths, 150 000 – 180 000 lost "Quality Adjusted Life Years" and costs 80 billion NOK every year it's time for some math:
In an article in "NRK Ytring" in August 2014 the president of the Medical Association (NMA) and director of the Institute of Public Health (NIPH) state that we should phase out smoking tobacco within 2035. In a follow-up article in "Bergens Tidende", the Minister of Health, Høie, was quoted saying that he envisions that with active policy measures, the smoking epidemic is over in 2050. If we multiply 150,000 lost QALYs and 8000 deaths per year with the NMA/NIPH's 20 years and the Minister of Health's 35 years of waiting, this gives us roughly 150 000 to 200 000 deaths and 3 million to 4 million lost QALYs.
Those are some pretty big numbers for such a small country. He then makes a very important point:
To put it very simply: It is the smoking of tobacco that is dangerous, much less tobacco itself. Tobacco is not harmless, but cancer occurs primarily when organic material is heated to 700 ° C in cigarettes and pulled into the lungs. Although tobacco has been in use for 500 years in Europe, lung cancer was a very rare form of cancer before the invention of the cigarette manufacturing machines in the late 1800s.
You see, the world does not actually have a tobacco problem, it has a smoking problem. So instead of asking how a tobacco product can be the solution to the tobacco problem, we (or they) should be asking: "How can a tobacco product be the solution to the smoking problem?" The answer, of course: Make sure you don't light it!

Leira finishes his commentary with some advice to the Minister of Health, quite different from the advice Sanner and Grimsrud gave in their article earlier on, which can be summarized as "regulate the hell out of vaping to make sure our eyes are not bothered with anything that remotely resembles smoking".
E-cigarettes contain controllable chemical substances and may, in principle, not contain any harmful substances beyond nicotine. Today, e-cigarettes are banned from being sold in this country and therefore unregulated, and we risk that many will import dangerous models from rogue manufacturers. We should rather do as the UK, who after a review of current research will allow e-cigarettes next year. According to the news the government may come to allow a tasteless version next year, but this will unfortunately not appeal to the group who need it the most. Similar devices are already legally sold under medical license, and have negligible prevalence.
Therefore, my advice to the Minister of Health is: Allow the sales of e-cigarettes with flavours and make them subject to content control, preferably through the Norwegian Medicines Agency. Encourage smokers to replace cigarettes with snus, e-cigarettes or nicotine gum. And finally: increase taxes on smoking tobacco and lower taxes on the replacement products. The goal for the health authorities must not be a tobacco-free society by 2050, but a cigarette and smoke free society much earlier.
I don't think I agree with the part about content control through the Medicines Agency, but apart from that, Leira makes an extremely important point in what our goal should be. Neither nicotine nor tobacco is the problem in itself, but the way it is consumed makes it a problem. Recognizing this will give the Minister of Health some invaluable tools and ability to come up with policy measures that will end the smoking epidemic much earlier than 2050, dramatically cutting down those horrible numbers I mentioned earlier.

I've heard lots of stories from fellow vapers about doctors with very positive attitudes towards vaping, after seeing the effects it has on their formerly smoking patients. It's great to see one finally going public with this, something I've been missing. It's the doctors treating former smokers on a daily basis that really see, and in many cases are even able to test, the effects vaping has on real people. I'd like to encourage them to do the same thing Leira has done: Share your thoughts in public! I'm sure a lot of doctors have the same experiences as Leira, and it's important that our politicians gets this information before it's to late.

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