Time to stop measuring risk as “fraction of risk from smoking”?

by Carl V Phillips

I ran across a tweet touting a press release out of the Global Forum on Nicotine (GFN) meeting (a networking meeting, mostly of e-cigarette boosters) that made the claim that snus is 95% less harmful than smoking. This was variously described as being based on “new data”, “new data analysis” and “the latest evidence”, but with no further explanation of where the number came from. Since the presenter was Peter Lee, those of us who know who’s who can surmise that it is a statistical summary of existing published studies, because that is what Peter does. There is nothing necessarily wrong with that (though for reasons I will explain in an upcoming post, it is potentially suspect in this context). but it is certainly not new data or the latest evidence.

Oh, and it is clearly wrong.

(Aside: I seem to recall a few instances when the GFN types screamed bloody murder about the science-by-press-release game after an attack on e-cigarettes was released to the press before the scientific community had a chance to review the evidence. Go figure. Well, you know, maybe I am misremembering. Also interesting is that most of those attacks on e-cigarettes at least had a sketch of the methodology in the press releases, coming from the press offices of scientific rather than networking meetings. So there was possible to partially assess what was actually being claimed and why, unlike the present case.)

For snus to be 5% as harmful as smoking, the cardiovascular disease risk from nicotine would have to be a bit worse than the worst-case estimates of it. (Contrary to widespread misperception, any plausible level of cancer risk is just a rounding error in comparison to CVD risk.) It is sorta maybe kinda possible this estimate is correct. But I would put the probability of the risk being a negative percentage of the risk from smoking (i.e., that snus use is net beneficial) as solidly higher than probability that it is 5% as harmful.

This was my reply on Twitter:

But after that tweet I found myself wondering whether the metric makes any sense whatsoever as a way to think about the risk of low-risk tobacco products, especially snus. This if for several different reasons I list below. And in case the significance of this point might need mentioning: I am saying this as the guy who pushed that way of thinking as much as anyone over the last couple of decades.

First, consider the absurdity of me having just written “a negative percentage of the risk from smoking”. The “fraction of the risk from smoking” unit has an Orwellian control-of-thought-via-vocabulary effect, constraining our perception: it tends to force us to assume the effects are negative. But it is quite plausible that the net health effects from smokeless tobacco are positive. There is a possibility that the same is true for e-cigarettes. The next-most similar exposure, drinking coffee, once believed to be unhealthy, is looking more and more net-beneficial. This is a simple one-paragraph point, but is as important as any of what follows.

Second, the scalar unit required to make such a comparison is not useful. What is actually being claimed in the press release? What was I saying in suggesting the effects might be positive? It is reasonable to expect that nicotine, like any stimulant, could trigger an incipient stroke or heart attack. But there is good reason to believe that it (perhaps in combination with other aspects of the tobacco exposure) is protective against neurodegenerative disease. If both of those are true, how does one decide which side of the 0% point these two —  let alone the myriad other possible effects — net out to?

The simplest statistic to calculate is to compare the risk of mortality attributed to smoking and to smokeless tobacco (taking the former from existing calculations and calculating the latter). This is what I did in what is, as far as I know, the only attempt to calculate the comparative risk (and, yes, I say that having read that press release; it is possible that Peter actually did this, but it is far from clear). This is also the unit that Brad Rodu, who was also a coauthor on my analysis, used in the first cut at this from a decade earlier. (His analysis was based a “what if” for a highly exaggerated risk for oral cancer from smokeless tobacco, with no other risks, so it did not really do the job. Also there was a double-counting error in the calculation.) For what it is worth, my analysis put the risk at 1% that from smoking, while Brad’s came up with 2%. Note that these are gross-risk estimates, ignoring the benefits that should be counted on the other side of the ledger.

However, even that seemingly clean unit is pretty iffy. A death attributed to a particular disease event, that in turn is attributed to an exposure, is not actually all that meaningful. It is not even terribly meaningful if we distill it down to deaths attributable to a single disease. It obviously does not make sense to just chalk up a fatal stroke in a 20-year-old alongside one in a 90-year-old.

Moreover, for several reasons I have explained on this page previously, the meaning of “exposure E caused a death” does not mean what casual readers think it means. (See, for example, the first subsection here, which illustrates how fraught such statements are.) A few days ago I saw tweets ridiculing headlines about an exposure causing a 100% increase in risk of death. Such a figure is perfectly legitimate (setting aside whether the evidence really supported the claim in this case); it clearly means age-specific mortality rates are doubled. But the common misinterpretation leads to jokes about people dying twice.

If we want to measure deaths, we should at least be measuring years of potential life lost (YPLL). We would want to use as the denominator not the deaths among smokers that are declared attributable to smoking — the 1/3 of them, or 1/2 or 9/10 or whatever made-up number tobacco controllers are claiming these days — but the 5 or 10 years by which smoking shortens life expectancy. The “fraction of smokers who die from smoking” statistic is not actually meaningful (due to those complications I just alluded to) but YPLLs is. Calculating YPLLs for estimated or posited disease risks from a low-risk tobacco product is perfectly straightforward, but it is a lot of work and no one has ever done it.

But wait. What about that neurodegenerative disease thing I mentioned? That has minimal impact on the YPLL result. But most people would count five years living with severe dementia as worse than no dementia but dying one year sooner from a heart attack. And that is to say nothing of how to factor in more subtle health effects like reduction in depression or stress, or the simple acute increase in mental acuity and perkiness.

I spent a fair bit of my career doing cost-benefit calculations in the medical context. By far the most suspect part of that effort was creating a conversion rate between goods where there was no natural way to do so. It is hard enough to just put resource expenditures (i.e., money) and one health outcome (e.g., number of cases of a disease cured) in the same equation, though that is a well-worn path and there is a good way to finesse it. But as soon as there was a third consideration (e.g., Treatment A is more expensive than B; it saves more lives; but it is also causes a substantial period of serious pain), it became very difficult to be comfortable with the conversion rates used, let alone to defend them against criticism. One obvious good reason for this: Different people convert between pain and risk of death differently, so any summary average is not relevant to many actual decisions.

If you want to see a cartoonishly absurd example of trying to throw incommensurate considerations into a scalar measure, you need only look to the Nutt et al. paper about the impacts of various tobacco products (see my dismembering of it here) that is the apparent basis for the popular claim that e-cigarettes are 5% as harmful as smoking. It appears that the 5% number traces back, via a telephone game, to a misinterpretation of that paper’s silly aggregation of health, social, financial, and other factors as just being about health (as well as the little matter of ignoring that the paper is complete junk science).

Bottom line: Actually assessing “percentage of the health impact from smoking” would require collapsing the impacts to a scalar, which really does not work. The alternative is looking at only one particular outcome, measured in just one way (usually not a good way), which is inadequate.

Third. is the problem of anchoring bias. This is the common phenomenon of people not adjusting sufficiently from a starting estimate, or even a quantity that should really have no influence at all, in the face of evidence. This tendency is so bad that if you just show someone a random number between 1 and 100, and tell them it is just a random number, before asking them to estimate a percentage, their estimates will be measurably influenced by the random number (i.e., those who draw a bigger random number will systematically give higher estimates). A comparison to the risk from smoking, which causes more YPLL than any other common consumption choice, creates an anchor which will inevitably bias perceived risk upward.

Tobacco controllers love anchoring bias. It permeates their propaganda and makes it easy for them to collect useful idiots. By intentionally anchoring perceptions of all tobacco products to the risks from smoking, they actually prevent people from being able to assimilate the evidence about smokeless tobacco or e-cigarettes. But “tobacco products”, when used as a category of healthfulness, makes no more sense than “corn products”, which includes both soda and whole-grain health foods. Indeed, in terms of the magnitude of the differences in healthfulness, it is perhaps more like referring to the risks from “mushrooms” or “titanium products” (which include both military jets and cardiac pacemakers).

The risks from smokeless tobacco, e-cigarettes, and pharmaceutical nicotine products should not be anchored to the risk from smoking. As noted, the net health effect is quite plausibly positive. But even just looking at the negative side of the ledger, we are looking at a minor everyday-level health impact, a risk that should be compared to that from, say, exercising five fewer minutes or eating twenty more grams of meat per day. Of course few people have an intuition about the quantity of those risks. But the reality is that people who think they have an intuition about the risk from smoking are mostly wrong. The point is those everyday risks should be the anchor point. Indeed, the ignorance itself is really the right anchor. The perception, “I know that a bit more exercise is a little healthier, but I really do not know how much and am not going to worry about it”, is pretty much how someone should think of low-risk tobacco products.

Fourth, and related to the previous point, though a matter of real numbers rather than subconscious bias, is that the risk from smoking is a unit of the wrong magnitude. It is like quantifying the ingredients for a recipe in tons instead of ounces. Saying that an exposure causes no more than 5% the risk of smoking is like saying the nearest star is five-light years away while Pluto is less than 5% of a light-year away. True, yes, but it grossly understates the difference.

The point is one that I have discussed at length (example). Saying something is “only 5% as much!!!” sounds great out of context. But in this case, the unit is like a light-year. Something that really were 5% as harmful as smoking would still be the second-greatest risk of any common consumption choice (assuming, of course, that it were reasonably common, as smokeless tobacco use is in northern Europe and North America, or e-cigarettes are in the UK, the USA, and other places). That leads to the springing of this trap (also from GFN):

The problem is that starting with this wrong unit means that useful measurement must take place way down below the decimal point. But instead of that happening, people tend to treat all small fractions as the same. It is much the same problem with risks that are expressed in terms like “this pollutant you are being exposed to causes a .001 chance you will get cancer”, which gets basically the same reaction if the number is .01 or .00001.

It is a big difference, a genuinely big deal, whether the gross risks from smokeless tobacco are 99% lower than smoking, or are 98%, or 99.9%, let alone merely 95%, but those numbers get thrown around as if they are all interchangeable. When looking at a choice between smoking and using smokeless products, this difference is a rounding error. As I have tried to emphasize throughout my work on this topic, the risks from smokeless products are within an unimportant rounding error of 100% harmless. This is why the cynical “continuum of risk” myth is so harmful: it obscures the fact that on a scale that includes the risk from smoking, there is no continuum, only two points: 100% and ~0%. But “to smoke or to snus (or vape)?” is not the ultimate question. Even if it is the question for someone sometime, there is later the question, “should I now quit snus/ecigs too?” The difference among those rounding error level estimates, let alone between them and a net benefit, would cause many people to make different decisions if they were making a rational assessment.

Fifth, smokeless tobacco use is mostly not about “to smoke or snus?” In the 2000s, when those of us working on tobacco harm reduction thought smokers could be encouraged to switch for risk reduction, this was the right question and so the “percentage of the risk from smoking” meme was the best way to think. This perhaps turned out to be the useful view for Norway, the only place where widespread switching actually took place. But in the other major legal markets — Sweden, USA, Canada — smokeless users are smokeless users, for the most part, not would-be smokers. The dominance of snus in Sweden is a cultural phenomenon, not an anti-smoking phenomenon (despite often being portrayed that way). Despite efforts to promote switching in North American, smokeless use is overwhelmingly concentrated in subcultures where it is the cultural norm, not an volitive substitute for smoking. I do not want to overstate this: Many smokeless users in the USA and Sweden switched from smoking, and we can predict that many more would be smokers in a world that had just cigarettes and not smokeless. There are many dual users who could be persuaded to settle on smokeless if they knew the rough comparative risk. Nevertheless, smokeless use should not be thought of as a variant of smoking.

So, given that most smokeless tobacco users should not be modeled as would-be smokers, a measure where actual quantification of the risk they face is lost in the rounding error is not useful. Should these consumers consider giving up their consumption choice for health reasons? The fact that the risk is some tiny fraction of that from smoking is not a useful answer.

Note that this argument is not quite the same for e-cigarettes. Setting aside the over-hyped but really rather trivial issue of experimentation by teenagers, e-cigarettes are all about substituting for an existing smoking habit. That is a large part of why a faction of tobacco controllers have embraced them (and, indeed, pretty much taken over the mindspace around them) despite continued hostility toward smokeless tobacco. Still, after giving up cigarettes and settling in to never going back, there is still the next question of whether to give up e-cigarettes because it might reduce health risk. So long as the estimates of that risk are imprecise fractions of the risk from smoking, the needed information is missing.

In conclusion, I am sure it is safe to say that everyone will ignore these concerns and keep using the same flawed phrasing. The obvious comparison is Karl-Olaf Fagerstrom declaring, five or six years ago, that the “Fagerstrom Test for Nicotine Dependence” is really only a measure of cigarette dependence, that he had it wrong, and it should be relabeled and not used outside that context. This has been almost universally ignored, presumably mostly because ignoring that advice is much easier than heeding it. Indeed, it is probably safe to say that I will keep using the same flawed phrasing sometimes, though I will try to nudging things in the right direction. Perhaps I will even live long enough to be able to say “who could have predicted that it would become apparent that this was the wrong way to describe the risk from low-risk tobacco products?”

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34 responses to “Time to stop measuring risk as “fraction of risk from smoking”?

  1. Insightful & worthwhile points, indeed.
    However I’m compelled to remind you that years ago when you were first involved with CASAA, you were vocal in your opinion that it was a waste of effort to argue against calling e-cigarettes tobacco products. I remember because that’s when I stopped believing in their effectiveness as an advocacy group.

    Even a non scientist like me (as well as Stevie Wonder) could see the anchoring bias train rolling down those tracks. A pity that I wasn’t able to articulate that better at the time, but I’ll keep nudging as well. Granted that there is a stronger relationship between users of cigarettes and e-cigarettes than there may be between cigarettes and snuff or snus, and that the two former products themselves can be physically similar, they all have always been very different products.

    Gotta love hindsight. If there’s no other good, it at least causes one to think.

    • Carl V Phillips

      So how did all those “e-cigarettes are NOT!!! tobacco products, and therefore we should…” efforts work out? (Hint: You are talking about anchoring beliefs about a stick you inhale a nicotine aerosol from. It does not exactly depend on category labels that this anchors to beliefs about smoking. Similarly the silly debates about trying to get people to not call them “e-cigarettes”.)

      The problem is not including things in the category “tobacco products”, which is a perfectly normal and useful categorization for many purposes. The problem, as I just explained here and in the context of those pointless efforts, is it is misleading (either intentionally or inadvertently) to imply that different items in the category have similar health effects. They do not, and this remains just as true even if you gerrymander e-cigarettes out of the category.

      • Still defending that?
        I can fish for a horse with a pole & hook and might even be somewhat successful.

        But if I want to engage in meaningful conversation about successful fishing, it helps if everyone in all parties recognize that we are talking about water creatures, and specifically ones with mouths, fins, and gills.

        Obfuscating the subject in question is simply counterproductive and a waste of serious effort, imo.

        And finally, the subject is slowly turning to nicotine, but still obfuscated through the traditional lens of combusted tobacco delivery as its obvious origin.

        I suspect that you are mostly perturbed that you can’t divorce your product of choice from the tobacco plant as much as e-cigarettes can. I may be wrong, but I think not.

        • Carl V Phillips

          Your understanding of my views and statements seems to be exactly backward. The one bit that is on-topic for this post is just the observation that any category that includes both smoking and snus use (with or without vaping) is not a useful category for health risks. As I said, like mushrooms.

          My broader point (which is off topic here, and thus I ask that if you wish to continue this conversation you find a recent post about it (look for something criticizing Mike Siegel’s obsession with this) and post there; I will watch for it) is not that a particular definition of the category “tobacco products” is right. It is that it and any other categorization can be delineated in various different ways, chosen to be suitable for some purpose, and thus no non-absurd delineation can possibly be WRONG. So that category can be defined based on regulatory goals, production inputs, sociological or economic niche, how retailers shelve products, and any of quite a few other considerations. Arguing about favorite category definitions does not change reality (an indisputable truth) and has a pretty trivial effect on rhetoric (an empirical claim). Thus my point has always been that actually caring about this is an error and declaring that someone’s position is FALSE (the Siegel follies) is patently invalid.

  2. 100% agree with everything in this. Comparing anything to smoking is a losing game. The real assessment should be comparing something with nothing. i.e. the risk of doing something, smoking, drinking alcohol, using a drug etc to not engaging in that activity. This is the metric used to judge a medical intervention which may have negative effects but compared to not using it, is beneficial.
    However, in the case of “reduced risk tobacco products”, (see how the framing is biased already!) there is a specific option to compare against, smoking. While I agree, the comparison system is totally inappropriate, it is the context this battle is being fought in. I doubt changing this system is something we can do now, it’s a long-term project, and the battle to extend the options for nicotine users is being fought right now. In an ideal world, we could pick the field of battle but this fight has been brought to us. We have to fight on their terms for now.
    Or to move away from military imagery, we have to persuade our opposition ‘where they live’ using their framing until they are at least amenable to engage with us.

    • Carl V Phillips

      I should say that I am not advocating abandoning reactionary use of the comparison-based stats. So, for example, in a discourse where you are specifically responding to “sure it is somewhat lower risk, but it is still a harmful tobacco product”, then the obvious and reasonable response is to point out that 99% lower is more than just somewhat lower. I guess I should characterize the recommendation as being about “primary information” or “scientific analysis” or something like that — i.e., when presenting the general information, not as a reaction.

      I agree about “reduced-risk tobacco products”. I have always objected to that and always refused to use it. The other reason for that is that the words describe an action (reduction) that did not take place. The low risk from these products was ALWAYS the case, not a reduction.

      • If only the categories were rational- based on actual physical and chemical qualities i.e. ‘smoke’ and ‘smokeless’ .

        • Carl V Phillips

          That is basically my observation here about the continuum lie: There are two points. They are so far apart that they obviously do not belong in the same category, IF the category is being used to collect similar healthfulness effects. (IF because, as I said, you can create a category definition to serve whatever purpose).

          It may not be QUITE that simple. Minor products might fall in between. HnB might fall in between. But it is pretty much that.

        • natepickering

          But here we get into the magical thinking and emotional totem-building of the tobacco controller. These people are exhaling a smoke-like substance, and they seem to be enjoying themselves, so this is clearly the work of Big Tobacco.

  3. I’ve been amusing myself with a calculator regarding your nearest star and Pluto comparison.
    A light year is 5,865,696,000,000 miles. Round it to 6,000,000,000, 000 miles for easy working. 5 light years is 30,000,000,000,000 miles.
    The distance to Pluto is approx 4,500,000,000 miles.
    The distance to Pluto is thus one 60th of 1% of the distance to the nearest star, or 0.0166….. % if you prefer.

    Thus, it could be said that using an ecig is 99.984% safer than smoking.
    Would Arnott STILL say that: “Smoking is so very dangerous that even something 99.984% safer is still not harmless”? And how would she account for the time lapse between the cause and the effect?

    I have read your earlier posts about the 5% estimate being wildly exaggerated, and I think that you are absolutely right to be annoyed about such estimates. Further, I agree with your thinking about the benefits of the use of tobacco in some forms. I like to think in terms of the difference between warming your hands in front of a fire and thrusting your hands into the fire.
    But, there again, I feel the same about ‘Environmental Tobacco Smoke’. Are there general benefits from the air-cleaning effects of such smoke? Or is such talk verboten?
    As a couple of commenters above have said, anti-nicotine beliefs are so deeply entrenched that it is very, very hard to counter them.
    It would be nice to find a way to ‘move the goalposts’ just as TC does effortlessly.

    • Carl V Phillips

      Yeah, I was mildly amused by that comparison when I came up with it. Of course, we have measured those distances to great precision (I am not sure exactly how much. My over-under guess would be five sig figs for Pluto and three for Alpha Whatever. Roberto, are you reading this?) Whereas the estimates for smoking, though typically stated to three sig figs are not really even good enough for one sig fig. For snus and ecigs, we are not even sure of the order of magnitude or sign.

      I suspect the Arnott type claim would not be made about 99.x% reduction. That is why the 95% claim is so harmful and it is so absurd that the people who endorsed it are so desperate to defend it and not admit their error. And, yes, it is still an error to say “at least 95%” if the true value is 99.984%, even though it is technically true.

      I like the fire metaphor. I will try to remember to use that.

      So are you saying that ETS is a disinfectant? I have not seen such a discussion, but presumably there is some such effect. PG is an aerosol disinfectant, and vaping advocates were trying to make a deal of this for a while — perhaps still are, but I have not seen it in a while. Of course, airborne infectious agents are not a big deal in most places.

      • natepickering

        “That is why the 95% claim is so harmful and it is so absurd that the people who endorsed it are so desperate to defend it and not admit their error.”

        And it gets more harmful and more absurd as time goes on, because now it’s been (predictably) transmogrified into “up to 95% safer” by a large segment of the dim-bulb vape activist community.

        • Carl V Phillips

          Interesting. Good to know and add to my analysis. I had not observed that. It goes nicely to my point (often made in response to Clive Bates) that “at least 95%” and “95%” sound the same to most people. This extends it to “up to 95%” sounding the same also.

          Of course, advertisers know that. Phrases like “up to X” are very common games for them.

      • Just one point which I mentioned briefly which you have not taken up.
        What sort of timescales would, say, ecig vapour need to do significant harm? I find it horrific that Arnott et al dare to claim that the ‘5%’ danger occurs over the same timescale as smoking.
        The timescale is THE MOST IMPORTANT THING. Why are not Professor Siegel and others not talking about it?
        Doll’s ‘Doctors Study’ indicated a definite timescale. The more that you smoke and the longer that you smoke, the more likely that you will die from lung cancer or something else, as compared with non-smokers. Little attention is paid to the timescale aspect of Doll’s research – the LONGER that you smoke, the more dangerous that it is. His graphs, biased though they might be, reveal that ‘truth’.
        So how long would exposure to toxins in ecigs, chewing tobacco, snus, take to kill a person, or increase YPLL? Would such exposures require hundreds of years to have a mortal effect?

        • Carl V Phillips

          I have a post in the archives about what we would be able to predict about the effects of smoking if it appeared as a brand new practice today. The answer is a lot, because we could extrapolate from other knowledge. Most elements of the ecig exposure are already pretty well understood for substantial and fairly long-term doses (from occupational exposures). From that we see little reason for worry, even for the fairly long term. However, it is true that some of the doses and possibly the calendar time of exposure (if many people actually end up vaping for life — not a foregone conclusion) exceed any existing observations. So it is certainly possible something will show up in the longer term. That is one of the reasons why it is the safe bet that vaping is more harmful than ST use (which we do have long-term observations for).

      • Roberto Sussman

        Our nearest extra solar stellar neighbor is Proxima Centaury at 4.3 light years away. Indeed, comparing inter-stellar and solar system distances is one way of illustrating how a given quantity can be vastly smaller than another taken as standard. This type of analogy is roughly appropriate, IMO, when comparing concentrations of potentially toxic chemical components in e-cig vapor with those present in cigarette smoke, but one needs to be careful with the numbers because 0.001 is not the same as a 0.000000000001 and also because relative concentrations vary a lot. Reasoning by analogy is only helpful when done carefully (numbers and involved factors must be actually measurable and comparable).

        I know that assessing health risks (relative or absolute) is very complicated and cannot be reduced to comparing vaping and smoking in terms of the relative concentrations of potentially toxic compounds. However, if we assume that risks can be (somehow) evaluated from these comparisons, the 5% number is grossly misleading because it is a huge number far above the magnitude of these concentrations in vapor with respect to smoke. In fact, as you rightly mention, the 5% risk from vaping in comparison to smoking is closer to the risk from smoking (the 100% in this comparison) than to the risk that could emerge from comparing measured concentrations in vapor and smoke.

        • Carl V Phillips

          Health effects of exposures are usually nonlinear, often very much so. So just multiplying by the quantity of the exposure in smoke is not likely to be useful at all. However, across the relevant range, they are almost(!) always monotonic. So when an occupational exposure proves harmless (harm is below limits of detection), a lesser consumer exposure is almost certainly so. That covers a lot of the chemicals.

          The bit about people not “getting” orders of magnitude differences below the decimal place goes to my point about.

  4. Just one point that I have a slight disagreement with, and that is the idea of culture being a dominate force in the use of smokeless tobacco.

    Culture is pretty plastic. It can change (and sometimes radically) between generations. Even in Sweden with it’s long use of snus, it hasn’t been until the current under 30 population that snus use among women is now nearly the same as for men under 30 (I haven’t been able to completely confirm this but what I can find is coming from good sources). I have to believe that what has prevented a larger scale switch to ST in the US is the gross misinformation about risk. If someone is told the risk is essentially the same, why switch, especially when cigarettes are such a kick-ass delivery system.

    Of course there are people who started with ST. It has been around a long time. But for smokers who learn about relative risk, for many what is used is simply what is convenient at the moment. Switching between vaping and ST, and back again, is routine. There would likely be more of that (which would be a very good thing for consumers) if much of the vaping media in the US hadn’t turned pretty much anti-tobacco (interestingly not so much in the EU, where they don’t have ready access to ST). The only place I have found where ST is discussed on a regular basis is the CASAA Facebook page, and even there the bad information comes up on a regular basis. Decades of brainwashing have taken its toll.

    It is not culture, it’s information. With good information people use whatever low risk product is convenient. It is all interchangeable for the consumer.

    • Carl V Phillips

      Perhaps. I certainly agree that a particular cultural influence can expand or contract. ST was the norm for women in the U.S. rural east for a good part of the 20th c, until it they got the message that smoking was much more womanly. I assume that the undoing of that same message is what is going on in Sweden (though I am far from expert on that point).

      But regarding misinformation, what you are saying is what many of us were saying for a long time. And trying to do something about it. And getting nowhere. Of course it is perfectly plausible to conclude we just failed to pull off something that could have been done. And thus it could still be done. But perhaps not. There is also the fact that the subcultures where ST use is most common in the USA do not exactly attract much cultural imitation from those in other subcultures. So the strong culture that exists is a barrier to expansion. Anyway, it may well be that it is all about the successful disinformation, but that does not change my point. For now — and despite efforts to change this — it is mostly an narrow cultural phenomenon to this day, and thus the point (about being its own thing that should be analyzed in a useful manner for those who own the thing) still stands, albeit not as strongly as it does for Sweden and environs.

      As for switching being routine, I think you may be over-concluding from a chattering class of literally only a few thousand people. I realize that I don’t actually recall seeing the statistics for this ever, but I would guess that ST-ecig dual use is a quite small portion of US ST users.

      • natepickering

        I think most people in the US still have no idea what snus is. I find myself constantly explaining what it is to people, practically every time I pull the can out. I often wind up giving samples out, and everyone seems to love it. They’re amazed that you don’t have to spit and little bits of tobacco don’t get in your teeth. Especially with women, those are the main reasons they’re disinclined to try American-style ST. I have one female co-worker whom I’ve successfully transitioned to snus (she didn’t take to vaping) from about 35 years of 2 PAD.

        • Carl V Phillips

          Most of the time when I use “snus” I am referring to any Western ST product (perhaps excluding chew, but not always). If the option to easily use in the upper lip is the key (for that is basically what you are talking about), there are American style (which basically refers to a flavor palette) pouched products.

        • natepickering

          Do the other pouched products eliminate spitting? I have never tried them and thus don’t know, but if it’s just American style moist snuff in a pouch, then probably not.

        • Carl V Phillips

          Obviously it all depends somewhat on how inclined to salivate the stimulus makes you. To some extent that can be learned. Oh, also you can acquire the skilz to hold loose ST up (albeit toward the front only). Anyway the difference you are thinking of might be that American products all tend to be quite moist, while many (not all) Swedish products are considerably dryer. That means — to get down to the bottom line that some people find gross — it does not take as much saliva being absorbed before it starts to drip. But I cannot imagine why the amount of saliva being absorbed would change with variety of ST.

  5. Talking about ‘culture’, my Dad was a coal miner. Miners were, of course, not permitted to smoke in the mines. Thus, amongst smoking miners (the majority?), chewing tobacco was the answer. Thus, there was a ‘culture’ amongst coal miners to chew tobacco when underground.
    I dare say that there were lots of other occupations where chewing tobacco replaced smoking in the working environment.
    Further, chewing tobacco promoted spittle, which helped to capture dust and keep dust out of the lungs.
    It would be interesting to know how snus became ‘the culture’ of Sweden.

    • Carl V Phillips

      Someone could argue the semantics of whether this practical motivation for that (and other) occupational communities counts as a “cultural” effect. I was including it.

      The short version of the canon Swedish story is that it remained common enough in the revered rural everyman that when the counterculture phenomenon of c1970 hit, returning to such rustic roots was an counterculture statement for the urban elites. Of course, all such history stories have a bit of just-so to them. (Note that no similar phenomenon would have been possible in the USA because the ST using communities were seen as part of the reactionary elements that counterculture was counter to.)

  6. Wonderfully done as always Carl! When ya gonna stop back in Philly and go pubbing again? :)

    You spoke of “The Fagerstrom Test for Nicotine Dependence.” I’ve played around a bit with the concept of creating “The McFadden Test for Chocolate Dependence.” With a series of questions attempting to mirror those for the Fagerstrom Test, I believe I had to conclude that I am a hopeless chocolate addict. Obviously chocolate should never be sold or given to children under the age of 21! It alters their brain chemistry and spirals them down toward a lifelong path of obesity and decadence (I’ve got the decadence part down OK, but having trouble with that whole obesity thing at 115 pounds. Sheesh, I’ve eaten over TWO TONS of chocolate in my lifetime and I’m STILL at 115 pounds! ::sigh::)

    – MJM, Chocolate Addict

  7. As I was quibbling on Twitter with your statement that “something that really were 5% as harmful as smoking would still be the second-greatest risk of any common consumption choice.” I did a little quick scan of what the CDC says about YPLL on smoking vs alcohol. I think they put alcohol at 2.5m years annually, and tobacco at about 5m – with all the caveats that go with those numbers that it is impossible to extract really good data of this sort and might be comparing apples and oranges (well, they are both fruit.) Wouldn’t 5%, as bad an upper estimate that it is, be so far below alcohol and other things (like poor diets) that it really does make smokeless pretty insignificant even at that made up 5%?

    I hate the 5% figure for a lot of reasons, but it is the one that is starting to bring people around. In fact, I almost feel like PH can swallow a bitter pill like 5% better than it can handle “harmless”. It gives them hope that they will be able to do something about it in the future. As long as we quietly say the “5%, at most, in our wildest imaginations, and only if there’s an unknown unknown out there waiting to be discovered.”

    • Carl V Phillips

      So my observation about “second biggest…” is based on the following way of looking at things: If you plot every exposure on axes of “how many people do it” and “how much harm does it cause to each one” there is a “frontier” (economist talk) of exposures such that nothing exceeds them on both dimensions. To get a worse per-consumer outcome, you have to go to a less popular exposure. So smoking is clearly on the frontier. It dominates it, carves out a huge range on both dimensions. But obviously there are much more harmful choices made by quite a few people, just not nearly as many (mountain climbing, heroin, street racing). There are also risky choices that are made by a lot more people, they are just not as harmful (eating meat, recreational travel). So I was being intentionally sloppy with the phrasing about “second most that is chosen by a lot of other people”. The line for “a lot” is obviously arbitrary. What I was really thinking was that it would still be on the frontier, but for smoking. That is, the only exposure that is both more popular and more harmful is smoking. I still think that is true.

      The harm from alcohol is basically all in one or two percent of the population that drinks the most. Their risk is solidly higher than that from smoke-free tobacco products, but there are fewer of them, so not on the frontier. The “public health” fanatics try to scare the other three-quarters of the population who drink. But the reality is that most of them are getting a net benefit (which you can be sure CDC is not crediting back in their YPLL estimate!). So for smoking it is reasonable to just describe it as a single behavior, though there is obviously variation. But for drinking that is absurd. (Not attributing this to you, of course, but to the fanatics.) High-dose drinkers do suffer harms greater than high-dose smokers, but a lot, even though median drinkers are better off than non-drinkers. Calling drinking, in general, AN exposure, is kind of like calling eating an exposure.

  8. Carl, you are saying that is a safe bet that vaping is more harmful than ST. In your mind what do you expect it will show up from long-term vaping? Do you expect some mortal disease like lung cancer or COPD? LC and COPD takes decades to form from smoking and often a lot of smoking is needed. What do you think is the culprit in e-cigarettes for diseases? Flavors? Solvents (PG & VG)? Nicotine? Daily consumption? Type of vaping (MTL or DTL)?

    • Carl V Phillips

      I am not expecting anything, but chances are there is something, if you see what I mean. Similarly, I do not have a specific hypothesis about a specific culprit, but as you note there are several candidates. If we were to find some harm from nicotine itself, it would pretty much be a push for this comparison. But there are others. They might be benign or might be somewhat harmful. The same is true for any novel exposure (e.g., nanoparticle cosmetics; mass consumption of acai berries). The difference is that thanks to decades of observation we have narrowed the possible range for ST to “zero risk” or “risk below limits of detection” for every possible harm that someone has thought to look at. Because the tail beyond this is still a theoretical possibility for ecigs, that puts the expected value higher.

  9. Many thanks for this interesting post! I recently decided to quit my job and do something more useful (as a paper engineer I mainly worked on things like making the toilet paper softer). As I strongly believe that e-cigarettes can have a huge positive impact on peoples health and happiness, I opened a small vape shop in Cologne, Germany. Even though I know that vaping is much safer than smoking, I want to make sure to not letting my customers being exposed to any risks that would be easy to avoid. However, there is so much noise from people debating how healthy or risky it is compared to smoking, but there is barely any advice for shopowners like me. Therefore I am now reaching out to experts like you and ask: What can I do to reduce the risks for my customers? What criteria should I establish for “high quality liquids”? Currently we try to educate our customers concerning battery safety and only sell liquids that come in softener-free bottles and do not contain diacetyl, pentandione or acetoin. We recommend organic cotton over regular cotton, coils made of titanium over nickel and since I am not in it for the money, we also tell our customers that “less is more” and recommend devices which make smaller clouds at lower wattages. Do you have any suggestion on how I can further reduce the health risks for my customers? Or do you think my whole “trying-to-vape-safer” thing will never make a significant difference so it is not worth the effort? I would be really glad to get your opinion on this.

    • Carl V Phillips

      Kudos for your choice and your goals. I am not really the one to ask about optimizing the engineering of e-cigarettes. I could offer some input (e.g., I am pretty confident a few of the things you doing are really not helpful), but better to go to the top experts. I would suggest starting with ECITA.

      • Thank you so much for your reply! Great, I will contact the ECITA to get more info. Of course I am also very interested in your opinion. So which are the things you believe are unnecessary (or even counterproductive)?

        • Carl V Phillips

          Well, worrying about plasticizers in bottles is pretty much all chemophobia hype. “Organic” seldom matters for anything, though I have to say I don’t know specifically about whether there are chemical residues on non-organic cotton (which is normally washed and not consumed, so it matters little) that might matter when you are heating them and sucking them up.

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