Transcript Slide 1

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
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.
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
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!
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
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
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
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
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)
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
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-General’s “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
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
Tobacco Harm Reduction
So,
since harm reduction is standard policy,
and it can work so well for tobacco,
Why not?
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.
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
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
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
The “why not”s 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
So, what about the “why”?
Imagine a town or neighborhood in your
constituency with 10,000 current adult
smokers….
Consider
a modest
switch
to legal
Under
the status
quo,
with no
use ofsnus
snus
10,000
smokers
only
5,000
4500
quit entirely
only
5,000
4500
keep smoking
1000
switch to snus
about
1800
2,000
die from smoking
maybe 3 or 4
die from snus
almost 200 lives saved
in this population alone
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
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
And the EU’s 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
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).
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
Making new health-affecting policies is
always difficult
What’s worse, you can learn the name of the
police officer, vaccinated child, or other
individual who died due to a policy
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.
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)
.
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
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)
A nasty policy challenge
• Doing the right thing…
– making policy more sensible
– respecting people’s right to control their own
health
– saving lives
• …is harder than not doing it
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)
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
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…
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.
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.
Carl V Phillips
University of Alberta
School of Public Health,
Edmonton, Canada
+1 651 503 6746
[email protected]
www.TobaccoHarmReduction.org