Last year saw the 50th anniversary of the US Surgeon General’s Report Smoking and Health and triggered global efforts to prevent tobacco use. Over those 5 decades, US smoking prevalence has fallen dramatically from around 45%1 to just over 18%2. Europe has seen similar falls, but there remain a stubborn 28%3 who will not or cannot quit. What is to be done about them?

Tobacco control education efforts have been forceful; few smokers today can be unaware of the risks of smoking. Yet significant numbers of people continue to smoke – despite knowing that smoking dramatically increases the risk of premature death from a smoking-related disease.

In the US, for 2000-2004, the Centers for Disease Control and Prevention (CDC) reported that ~443,000 US deaths were attributable each year to smoking. By 2014, this has risen to ~480,000 premature deaths. The CDC reports that overall mortality among smokers in the US is about three times higher than among never smokers5. In the EU, smoking is “responsible for nearly 700,000 deaths every year. Around 50% of smokers die prematurely (on average 14 years earlier).”6

But if roughly a quarter of the population resolutely refuses to quit smoking, how else can these premature (and frequently particularly drawn out and distressing, not only for the sufferer, but also for their loved ones) deaths be avoided? The Tobacco Harm Reduction (THR) approach recognises that the harm from smoking comes from the smoke, and not from the nicotine, as first identified by Professor

Mike Russell in 1976:

“People smoke for nicotine but they die from the tar. Their risk of lung cancer and bronchitis might be more quickly and effectively reduced if attention were focused on how to reduce their tar intake, irrespective of nicotine intake.” 7

Unfortunately, however, those who hold fast to an ‘abstinence only’ approach suggest that adopting THR is less healthy than quitting smoking via total abstinence from tobacco products – but according to epidemiologist Dr Carl Phillips, this is factually incorrect:

“Unless the quitting to total abstinence were going to occur immediately, switching to a low-risk alternative is usually lower risk than trying to quit completely, even if the alternative has non-zero risk. This is because even a few more months of smoking before quitting poses greater risk than a lifetime of using the alternative product.”8

Indeed, Dr Phillips has produced a paper9, estimating the fraction of an eventually-averted premature death due to smoking, attributable to every smoker who switches to e-cigarettes (or any other very low-risk alternative).

While acknowledging that this is a ‘back-of-the-envelope’ calculation, Dr Phillips demonstrates that doing anything other than fully embracing the THR approach immediately is a deadly mistake.

In very brief summary, Dr Phillips examines the period from the first quarter of 2008 to the last of 2014. He begins by estimating the “expected value of premature deaths averted for each smoker who switches to e-cigarettes.”

He then “calculates how many Americans have already avoided premature death thanks to e-cigarettes.”

His method follows the approach used in his 2009 paper, 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.10

He starts from the generally accepted estimate (of the US CDC) that 50% of smokers will die prematurely from smoking, and “roughly reducing it to account for the possibility that [a smoker] will still die from smoking even if she quits now.”

He calculates that: “Adding up the resulting avoided deaths through 2014 Q4 gives approximately

16,000 premature deaths already avoided, 13,000 from CVD [cardiovascular disease] and 3,000 from other causes. About half of these would have occurred in the last 20 months.”


“Another 19,000 smoking-caused premature deaths have already been averted but would not have occurred yet.” (Naturally, deaths from other causes occurring subsequent to the averted death from smoking are not taken into consideration).

These are quite startling estimates, and perhaps a re-examination of the precautionary principle is needed on this issue. Clive Bates made this argument even before Dr Phillips’ calculations were published:

“If a regulator wants to come down heavily on a product like e-cigarettes because of hypothetical dangers, it has to take into account the lost benefits that might arise if it bans, restricts, or otherwise reduces the positive potential of the product. For e-cigs this is particularly salient as the benefits are to health, not just economic.”11

Bates points out that “this symmetry is almost always overlooked when activists make arguments using the precautionary principle.”

The message for regulators and policy-makers seems to be quite clear: look before you leap, and think before you introduce an Act – especially if you intend to fully uphold the precautionary principle 12.

Dr Phillips also comments on this: “If the FDA had succeeded in banning e-cigarettes in 2009, over 10,000

Americans who are now alive would be dead. It is in the order of four to six times as many people as were killed on 9-11, killed by the stroke of a regulator’s pen (and saved by Judge Richard Leon overturning the ban). Even if everyone quit smoking in 2015, or if e-cigarettes somehow were allowed back onto the market then, those people would still already be dead. […] There is a lot of work to be done to stop those who would choose to let smokers die rather than have an attractive alternative. But for the moment, we can celebrate the New Year on this positive note.”8

One of the major long-term failures of smoking cessation is the high rate of relapse, so adopting a lower risk alternative for the rest of the lifetime has the potential not only to reach more people sooner, but also to change the entire pattern of nicotine use and relapse.

Encouraging smokers to switch to a safer alternative could achieve the long sought-after tobacco ‘endgame’. Embracing this new disruptive technology could bring this about quicker. Is this an opportunity we can afford to miss?



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Katherine Devlin


ECITA (The Electronic Cigarette Industry Trade Association)

Tel: 01792 324438


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