Saving%20European%20lives%20with%20smokeless%20tobacco:%20a%20clear%20choice,%20a%20difficult%20choice

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Saving European lives with smokeless tobacco a
clear choice, a difficult choice

• Carl V. Phillips, MPP, PhD
• University of Alberta School of Public Health
• Edmonton, Canada
• www.TobaccoHarmReduction.org

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Harm Reduction

• As people involved with health research and
  health policy making, we try to reduce risks.
• Quite often, eliminating the activity that causes
  the risk is not possible / practical / sensible.

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Harm Reduction

• So instead of eliminating the exposure entirely,
  we try to minimize how harmful it is.
• research and create better options
• make those options available
• educate about safer choices
• encourage people to make those choices

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Harm Reduction

• We can accomplish harm reduction for
• illicit drug use, sexual behavior
• transport, workplace hazards
• pharmaceuticals, medical procedures
• And we can accomplish it for tobacco
• the only difference is how much greater the
  reduction is!

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Contrasting health risks tobacco is not a
useful grouping

• Cigarettes and other smoking tobacco
• ? amazingly deadly
• most everyone understands this
• estimated that about 1/3 of long-term daily
  smokers will die from smoking
• perhaps as high as 1/2 for lifelong smokers who
  never quit

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Contrasting health risks tobacco is not a
useful grouping

• Western smokeless tobacco (ST)
  ? more like coffee
• most people do not understand this yet
• mild stimulant effects, not much more

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Contrasting health risks tobacco is not a
useful grouping

• Tobacco is just a plant
• Nicotine is a drug, and like most drugs it has
  some minor health risks
• though also major benefits
• attention, relaxation, focus
• relief from depression, PTSD, schizophrenia, etc.
• Smoke is a very deadly exposure

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Smokeless tobacco is about 99 less harmful than
smoking

• this is our (my and my students/colleagues)
  calculation based on reviewing all of the
  existing epidemiology for ST and disease risk
• presented at epidemiology meetings and reviewed
  by experts in the field
• no other calculations have been made that
  challenge this as the best estimate

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Smokeless tobacco is about 99 less harmful than
smoking

• any risk for oral cancer is too low to measure
  (SCENIHR report)
• recent claims about pancreatic cancer are based
  on misinterpretations (working papers)
• no evidence of other cancers
• possible low risk for cardiovascular event
  (effect of stimulant)

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Smokeless tobacco is about 99 less harmful than
smoking

• The estimate is not perfect, but we do have very
  good evidence of the upper bound
• even if there is as big a risk for oral and
  pancreatic cancer as some have claimed,
• ST is still more than 98 less deadly
• even that big cancer risk and largest plausible
  cardiovascular risk, it still is not 5 as bad as
  smoking

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ST has 100 less impact on the health of non-users

• There is a strong push to reduce exposure to
  second hand smoke in Europe
• e.g., recent Health Consumer Protection
  Directorate-Generals Green Paper
• But available regulations
• impose burdens on merchants and law enforcement
• do nothing to reduce exposure in private spaces
  (may make it worse)
• punish, rather than help, tobacco users

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ST has 100 less impact on the health of non-users

• When someone switches to snus
• it completely eliminates the second hand smoke
  burden they impose
• in public places
• at home too
• but does not create a personal or economic burden
• no avoiding bars/restaurants (or driving drunk to
  get to somewhere to smoke)
• no standing in the rain to smoke, grumbling about
  the government

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Tobacco Harm Reduction

• So,
• since harm reduction is standard policy,
• and it can work so well for tobacco,
• Why not?

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Tobacco Harm Reduction

• Why not reduce the harm?
• Some people think everyone will quit
• but many do not
• prevalence in the EU is over 30
• for several major EU countries and regions, it is
  more than 35
• almost nowhere has it dropped much below 20
• where has it dropped much lower? Sweden.

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Tobacco Harm Reduction

• Why not reduce the harm?
• Some activists argue tobacco should be banned, in
  all forms
• but it is legal (in some forms)
• a total ban not being considered
• ban seems unlikely and probably unwise

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Tobacco Harm Reduction

• Why not reduce the harm?
• Some people are concerned that total tobacco use
  might increase
• but the reason we are so worried about tobacco
  use prevalence is that smoking is a very serious
  health hazard
• tobacco use that poses a minimal health hazard
  should not provoke the same concern it is a
  legitimate individual choice like many minor
  risks
• net health effects certain to be positive

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Tobacco Harm Reduction

• Why not reduce the harm?
• It is difficult to change a policy like the ban
  on snus
• I understand (not as well as you do, of course)
  and will try to offer some thoughts at the end

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The why nots are really not so compelling

• large population continues to use tobacco
  (smoking mostly)
• smoked tobacco is not going to be banned anytime
  soon (if ever)
• it is misleading to think of tobacco as killing
  hundreds of thousands of Europeans per year it
  is smoking tobacco

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So, what about the why?

• Imagine a town or neighborhood in your
  constituency with 10,000 current adult smokers.

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Consider a modest switch to legal snus
Under the status quo, with no use of snus
10,000 smokers
5,000 quit entirely
5,000 keep smoking
only 4500 quit entirely
only 4500 keep smoking
1000 switch to snus
about 2,000 die from smoking
1800 die from smoking
maybe 3 or 4 die from snus
almost 200 lives saved in this population alone
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• So, with snus, more tobacco users,
• but many fewer deaths,
• even if snus is not very very popular.
• If this population replicated the Swedish
  experience, only about 2500 keep smoking rather
  than 4500,
• resulting in five times the number of lives
  saved about 1000 saved from 10,000

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• Of course, the EU does not have only 10,000 adult
  smokers.
• It has over 100,000,000.
• Moreover, about 25,000,000 are
• men
• old enough that they are likely to continue to
  use tobacco
• young enough to save their health by switching to
  smokeless

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• And the EUs policy on this has effects well
  beyond Europe
• smoking is increasing in the developing world,
  creating more need for tobacco harm reduction,
• Sweden led the way on THR, but Scandinavia alone
  has limited influence on other countries,
• the USA will eventually become a leader, but it
  is slow (Swedish culture is not well known in
  North America so little influence from there),
• if a billion smokers throughout the world are
  going to be led to THR anytime soon, it must be
  Europe that leads them

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• An easy calculation.
• That does not make it an easy decision, of
  course.
• But it appears by my reading (admittedly, I am a
  scientist, and not in politics)
• SCENIHR reported that the science is on the side
  of making snus a legal regulated product
• but taking action is ultimately political
• (and so are the arguments).

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Making new health-affecting policies is always
difficult

• Doing the right thing for the most people often
  hurts someone
• police are injured in the line of duty
• soldiers are killed when deployed
• vaccines harm a few children
• a reduced-harm exposure (even 99 reduced) still
  probably harms someone

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Making new health-affecting policies is always
difficult

• Whats worse, you can learn the name of the
  police officer, vaccinated child, or other
  individual who died due to a policy

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Making new health-affecting policies is always
difficult

• You will never know who the thousands of people
  are who were saved by the policy.
• The will probably not know themselves.
• They will never be able to thank you.

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Changing an existing policy is inherently
challenging

• An individual can choose to use smoke or not,
• and later decide he made the wrong choice,
• and then change his behavior
• (perhaps switching from smoking to snus)
• .

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Changing an existing policy is inherently
challenging

• But when a government makes a decision
• (e.g., deciding that no one will use snus),
• a constituency forms around the status quo.
• They know who they are and what they want.
• Those who would benefit from change are much less
  organized and so are not heard

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A nasty policy challenge

• Stick with the status quo, and receive vague
  criticism for preventing THR
• But remember staying with the status quo is just
  as much a decision as any other decision!
• Support a change and
• deal with the attacks of the puritans and
  financial interests that want snus to stay banned
• be blamed for some young person who is claimed to
  have disease due to snus use
• (claim is probably wrong, but that is little
  comfort)

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A nasty policy challenge

• Doing the right thing
• making policy more sensible
• respecting peoples right to control their own
  health
• saving lives
• is harder than not doing it

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But if you do help your fellow Europeans make the
harm-reducing choice,

• help snus become regulated but legal,
• and so as widely available as smoked tobacco
• try to let people know how much lower the risk is
  than smoking (or let others tell them)

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But if you do help your fellow Europeans make the
harm-reducing choice,

• Then it is likely that millions of European
  smokers will switch to snus over the next few
  decades
• This will help clear the air and save a large
  portion of them from a premature death

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• It is sometime hard to be motivated by counts
• 1000 out of 10,000 smokers
• or even millions across Europe
• So maybe think of this this way

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• Ten years after you start allowing smokers to
  make the choice to reduce their risks,
• somewhere there will be snus-using grandfather.
• Had he kept smoking, he would have died before
  his own child finished university,
• but because snus let him quit smoking, he met
  his grandchild (and never breathed smoke at her).
• You will not meet him
• but you will have saved him,
• and many thousands of others like him.

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• Ultimately, that is what all the scientific
  calculations and policy debates are all about a
  choice both clear and difficult
• choosing to maintain the status quo
• versus
• acting to save those many lives.

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• Carl V Phillips
• University of Alberta
• School of Public Health,
• Edmonton, Canada
• 1 651 503 6746
• cvphilo_at_gmail.com
• www.TobaccoHarmReduction.org