by Carl V Phillips and Elaine Keller
In honor of the birthday of one of us (EK), we are using the great title that the other of us wishes he had thought to use for his 2009 paper. In acknowledgement of her birthday, Elaine posted this yesterday on the Facebook CASAA members group:
Today is my birthday. My birthday wish is that e-cigarettes had been invented in 1983 instead of 2003. I was reluctant to share with the world that I was diagnosed with lung cancer last summer. I was afraid that some tobacco control liars might use that information to falsely accuse e-cigarettes of causing cancer. But an important fact is that for ex-smokers, the excess risk for lung cancer doesn’t go away the day you quit. In fact, it hangs around for a good TWENTY YEARS after you quit smoking.
So if I had been able to quit smoking in 1989 instead of 2009, perhaps I would not have needed to have the lower left lobe of my lung removed in July, and to go through chemotherapy. I’m happy to share with you all that my follow-up CT scan on December 4, showed no evidence of cancer. So I am officially in remission. To those who want smokers to wait around for 10 or 20 years for scientific proof that e-cigarettes are 100% safe, I say this, smokers don’t have that luxury.
Dr. Carl Phillips, CASAA’s Chief Scientific Officer, brilliantly analyzed the difference between being able to quit smoking immediately via switching to a reduced risk alternative source of nicotine (Tobacco Harm Reduction – THR) and postponing quitting until ready to “quit completely” (e.g., not needing to earn a paycheck after reaching the age of retirement) in “Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments.”http://www.harmreductionjournal.com/content/6/1/29
Most lung cancers are not diagnosed until Stage 4, when survival rates are grim. I thank God, and credit e-cigarettes, for the fact that mine was caught at Stage 1.
Sure quitting tobacco products entirely was theoretically an option for every smoker in 1989, but how many did it? (Hint: not many.) E-cigarettes had already been manufactured starting in the 1960s (and even designed on paper in the 1930s, though we are aware of no evidence a device was ever constructed). Quitting tobacco products entirely was still an option in 1999, but how many did that? (Hint: more, but still not many.) That was about the time that a major tobacco company tried to bring a more modern e-cigarette to market, but, again, they were quashed by regulators. What would have happened if those options had not been banned? Some of the answer can be found in Elaine’s story and some in Carl’s New Year post here. Of course, low-risk tobacco products were on the market. By 1989 it was adequately clear that smokeless tobacco was low risk, and by 1999 there was no legitimate doubt. But that fact was hidden from smokers by a concerted disinformation campaign which was almost as effective at preventing harm reduction as the repeated bans of e-cigarettes.
If smokers had been allowed access to e-cigarettes and knowledge of other low-risk alternatives decades ago, millions would have switched decades ago. It is not difficult to imagine that the majority of those now smoking would have quit via THR, or would have picked up a low-risk product instead. (It is particularly easy to imagine it when you observe that it actually occurred in Sweden.) The lowest risk alternative clearly was promoting THR in 1989, not pushing for total elimination of tobacco products.
Some of those behind the disinformation, bans, and attempted bans — both today and historically — are genuinely evil or at least sociopathic. They have a personal preference for a world that is free from all tobacco products (for some baffling reason that they never explain), and they lie and otherwise violate social norms, causing people to suffer and die, in pursuit of that goal. (Indeed, some of them clearly relish that suffering.) But they are a small minority of those responsible for this. They would not have the power without the much larger cadre of useful idiots. Most people who consider themselves to be “tobacco control” are not evil or sociopaths, but given the turn that the tobacco control industry has taken — in particular, that its defining characteristic today is being anti-harm-reduction — they have become the useful idiots serving the goals of the extremists. They typically actually believe that trying to dissuade people from THR is good for public health. Why? Because they believe that pursuing THR poses a higher risk to smokers than does pursuing complete cessation.
They are wrong. Badly wrong. This is obvious to anyone who actually thinks about this issue in even a slightly sophisticated manner.
Their naive notion seems to stem from the fact that, technically, from a purely medicinal standpoint, using a smoke-free tobacco product seems to pose some health risk (though we do not know that for sure) while abstinence poses none. Thus, they (mistakenly) conclude, THR must be the higher risk alternative. But this is only true if all else is equal — in particular if they would have both come to pass on the same day — and that is seldom the case. Someone who really would just quit on a given day in 1989 will have done so. Everyone else would have been safer had they switched, as emphasized by EK in her testimonial, as calculated in CVP’s cited paper, and as appears in the calculation for CVP’s New Year post.
In short, promoting abstinence is not a safe alternative to harm reduction.
Of course, anyone with an understanding of public health should know this already. Is demanding sexual abstinence a safe alternative to encouraging condom use? Is banning a popular drug a safe alternative to regulating it? Is mandating the use of an extremely awkward safety device, that technically offers slightly better protection to those using it than a pleasant alternative, a safer alternative? The empirical answer to the latter requires a bit of technical knowledge, but anyone familiar with occupational health or the use of safety gear more generally knows the answer: Offer only a highly unpleasant choice and people will just not comply, choosing the riskiest option of foregoing safety equipment entirely instead.
If non-sociopathic tobacco control people only understood the simplest 101-level lessons from their own field, public health, they would recognize this. But instead they are manipulated by the extremists into being useful idiots. They are tricked into not even thinking through what they are doing and saying.
One additional observation is necessary for fully understanding EK’s personal note and fully appreciating the preceding passages: Abstinence is a very unpleasant alternative for many. A few (like EK) can articulate this and openly explain that being able to function — to be happy, productive, employed — depends on continuing to consume nicotine. Given a choice of smoking, with all its costs and benefits, versus abstinence, smoking is better. Many other smokers basically get this, and do not seriously want to quit, even if they cannot quite articulate it. No observer has any excuse for not understanding this. It is simple social science or, for that matter, basic understanding of the behavior of sentient beings: Given only the two choices, if people choose smoking rather than abstinence, then they clearly like smoking (all costs considered) better than abstinence. Anyone who wants to dissuade people from smoking, then, who observes this — and who has even half a clue — will immediately figure out that he needs a third option.
And if he has a little human compassion, in addition to having a little clue, this will not just be because promoting THR lowers risk compared to promoting abstinence. It will be because THR gives smokers who benefit hugely from tobacco use (or just nicotine) a lot of benefit in addition to getting them off of smoking.
But even for those who do not care about people and only care about risks, the answer is the same. You have been duped by extremists who care neither about people nor even about people’s health, but are just bizarrely obsessed with the N. tabacum plant. Demanding the elimination of all tobacco product use is simply not the lowest risk alternative.
Smokers do not have the luxury of waiting for some perfect solution. Those who presume for themselves the right to control tobacco users do not have the luxury of pretending otherwise, pretending they are not killing people. Those who effectively prevented THR for decades are responsible for the lung cancers of Elaine Keller and tens of thousands of others.
Nicely put… a variation on this argument is to factor in probability of relapse from abstinence to smoking, perhaps in response to a stressful life event, socialising with smoker friends etc. It may be that vaping has an ‘inoculation’ effect against relapse to smoking.
Yes. In my analyses I have tended to just make the unit of analysis the moment of final smoking cessation, without reference to the pathway. That makes your observation basically an input through that. That is, I point out that complete abstinence is unlikely to happen this week for any given individual, and one of the reasons for that is quitting without a substitute — even if it occurs this week — is very unlikely to be complete and permanent.
Another approach that emphasizes your point is to just look at cessation and relapse patterns. There is a lot written about that, though I am not aware of any good quantification. I think it would probably be fruitful to combine those into a more general quantitative analysis.
Probably your best ever, as it is simple and direct.
The only thing missing is mention of the clear financial motivation for virtually everyone who opposes THR, and how some industries – especially those that have most influence on policy – need to oppose THR (in order to protect smoking) as a priority.
How was it that the cancer was picked so early in stage 1,very,very lucky❗
Probably like mine was a CT or X-Ray for an unrelated problem. Most early lung cancers are picked up incidentally.
Carl, actually, you may be wrong in saying this: ” technically, from a purely medicinal standpoint, using a smoke-free tobacco product seems to pose some health risk (though we do not know that for sure) while abstinence poses none. ”
I was doing some (admittedly superficial) research on Type 2 Diabetes yesterday after noticing that according to CDC figures it seemed to jump from about 1% of the US population in the early 90s when smoking bans were just kicking in to about 6% today when they’re all over the place.
I’d say that, aside from the attractive correlation (a correlation that the Antis would jump all over as absolute “proof incarnate” if it concerned fourth-hand smoke and growing radioactive eyelashes on the tip of your nose) there are some good supportive arguments why there could be a correction. Here’s an exchange I had with a retired doctor over on Quora yesterday on the subject:
Liang-Hai Sie 1 vote by Michael J. McFadden
In mice, drinking water containing non caloric artificial sweeteners caused changes in their microbiome leading to glucose intolerance, the first step on the road to type 2 diabetes Gut bacteria, artificial sweeteners and glucose intolerance
Upvoted (Undo) • Share • Report • Tue
Michael J. McFadden
Michael J. McFadden 1 vote by Liang-Hai Sie
That would explain the incredible increase in diabetes over the last few decades. It seems like almost everyone with any weight on them is drinking diet soda as the norm now, and I think diabetes has actually gone up by 500% or more since 1959? See the third graph down at the external site of the NRDC: 5 graphs and 4 photos tell the story on obesity, diabetes & walking
The trend seems particularly steep since the early mid-90s when smoking bans started hitting it big in US workplaces after the ’92/’93 EPA Report. That leads me to wonder if perhaps people began either (A) drinking more diet soda at work as a substitute stimulant/reward-giver throughout the workday, or (B) drinking more diet soda to try to combat weight gain that went along with increased rates of abstaining from or quitting smoking.
The way to test that would be to compare the rates in states that were very slow to adopt such bans vs. states like California that jumped right in, or to compare increased diabetes rates among lifelong nonsmokers vs. smokers. That’s a bit more of a project than I’m up for undertaking right now unfortunately (heh, if I even knew how to get the data!), and I doubt you’d be able to find any agency willing to fund a grant for a result that could be so politically undesirable: you’d have to word your grant proposal VERY carefully!
(EDIT: OK, just did a quick bit of checking and found this at the CDC external site at: Smoking and Diabetes – Tips From Former Smokers:
“We now know that smoking causes type 2 diabetes. In fact, smokers are 30–40% more likely to develop type 2 diabetes than nonsmokers.”
Since I believe smokers have been quitting at greatly increased rates since the smoking bans began kicking in during the 90s, the research model could prove a bit challenging!
LiangHai gave me permission to share his comment, but he also added a link that leads to studies connecting smoking and diabetes, so for fairness I think I should share that here as well:
On page 538 in Chapter 10 of the http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf
they explain the causality between smoking and diabetes:
OK! That’s all fer now!
Grrr… the link didn’t come through properly for that diabetes reference.
For the first one:
instead of “5 graphs and 4 photos tell the story on obesity, diabetes & walking”
For the second one:
instead of “Smoking and Diabetes – Tips From Former Smokers”
The idea that abstinence poses no health risks is itself misinformed to put it politely. Abstinence leads to increased risks of obesity, diabetes, inflammatory bowel disease, Parkinson’s, Alzheimer’s, and depression, to name just a few increased risks. It also, again provably according to a lot of studies, leads to a decline in mental acuity, concentration, and reflex time –all of which ca, in turn, lead to physical peril. If these negative effects can be avoided through vaping, chewing, or even switching to additive-free cigarettes or cutting back on the amount smoked, all seem to be less risky alternatives, no?
Yes, there is definitely a case to be made that smokeless tobacco, and e-cigarettes also, does not have net health costs, but benefits. Undoubtedly this is true for some people. Of course, the conventional wisdom refuses to accept that, so consider this a “one fight at a time” approach. If you have that more sophisticated understanding, that that is a possibility, then you can add the caveat “even if it turns out that low-risk tobacco/nicotine products pose some small positive risk….” That is still an argument worth making since even if you recognize that smoke-free tobacco products may actually be good for you, you have to recognize that there is still a substantial chance they are slightly harmful on net.
Reading my mind again… I was thinking: “Why is the perfect the enemy of the good?” And voila! Here you posit the answer I couldn’t write. Thank you Carl and Elaine.
“One additional observation is necessary for fully understanding EK’s personal note and fully appreciating the preceding passages: Abstinence is a very unpleasant alternative for many. A few (like EK) can articulate this and openly explain that being able to function — to be happy, productive, employed — depends on continuing to consume nicotine. ”
A big Thank You to Elaine and yourself for articulating what I have never had the courage to say about myself.
Yes. There are people who need nicotine to function. To function like a machine, like is expected today. I am one. And I fully agree with waltc above. Yes, some of us need it. And so what? Is “needing something” only “permitted” if it refers to Pharma’s pills? Where they try to push all kinds of junk on you (statins etc), telling you that you “need” that junk? Although you are perfectly healthy?
Thank you for sharing this story.
And the next time somebody stares at me as if I was an alien because I happily vape 18 mg nic after 3 years of vaping, I will just tell them to stick it where the sun never shines.
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