Intended for healthcare professionals

Rapid response to:

Editor's Choice

Hold the line against tobacco

BMJ 2014; 348 doi: (Published 02 January 2014) Cite this as: BMJ 2014;348:f7686

Rapid Response:

Re: Hold the line against tobacco

I would like to raise several concerns about this editorial.

There are thousands of people now using e-cigarettes instead of smoking. A brief search would have turned up hundreds of testimonies from people who have tried everything and have been liberated from decades of smoking by e-cigarettes [1]. The UK surveillance data show no negative effects and it is consistent with e-cigarettes having a beneficial population effect [2]. The top investment analysts attribute at least part of the decline in cigarette sales to the rapid rise of e-cigarettes and some see e-cigarette overtaking cigarettes within a decade. This is not to favour anecdote over evidence, but just to remind the public health establishment and BMJ, that there is a different, far more positive and more life-affirming side to this story than a mere grubby corporate conspiracy.

The editorial would have been more convincing if you had reflected on the experience of oral tobacco (often known as ‘snus’) and public health. This smokeless tobacco product was banned in the European Union in 1992 as many of the same arguments were made by the public health campaigners: that it would be a gateway to smoking, that it would facilitate continued smoking and that it would divert smokers from the imperative of quitting. In reality, the precise opposite has happened, at least where sale of oral tobacco is still permitted in Europe. It acts as a smoking cessation aid, an alternative to smoking and diverts young people away from smoking onset. Sweden was granted an exception to the ban and now has the best tobacco-related health results in Europe, with Norway not far behind (a non-EU member in which snus is permitted and widely used). Sweden has by far the lowest smoking prevalence in the EU (13% compared to the EU average of 28%) [3]. Many experts now conclude that this ban is, and always was, unjustifiable on scientific and ethical grounds, and represents an egregious long-standing error in public health policy [4][5]. However, many public health activists still support a ban [6], though they have struggled to provide any coherent rationale for it. Their underlying objection to snus is like yours to e-cigarettes– the involvement of the tobacco industry. But they have put their enmity towards tobacco and the tobacco industry before what should be the real aims of public health: reducing the burden of cancer, cardiovascular and respiratory disease, and other harms arising primarily from smoking. That has blinded them to the health benefits from substituting cigarettes for a product likely to be 98-99% less dangerous than cigarettes. I do not think we should trust those with strong oppositional positions on e-cigarettes unless and until they have understood the lessons of the snus ban. You are in danger of making the same mistake: those who fail to learn from history are condemned to repeat it.

You take at face value the analysis of Marisa de Andrade and colleagues [7], in seeing e-cigarette marketing as a threat to public health. It requires heroic contortions of logic to regard the emergence of a product that is perhaps 99-100% less risky than cigarettes and a viable alternative to smoking as an adverse development. 28% of Europeans still smoke, and it is an unequivocal, unambiguous good thing that they can switch to alternatives with negligible risk, even if they decide not to quit nicotine completely. There is, therefore, a much more favourable and optimistic way of understanding the marketing of e-cigarettes than that advanced by Cancer Research UK and the researchers it funds. It should really be seen as a disruptive intrusion into the cigarette industry: a new high technology product entering the market for the popular legal recreational drug, nicotine, and posing a threat to the dominant and most harmful delivery system, the cigarette. More effective, more edgy marketing could mean more success in persuading smokers to switch and quit smoking. Even if it means a few others use nicotine that would not otherwise have done so, we should be proportionate in our concern, as they will not be significantly harmed by it. In contrast, those persuaded to switch from smoking will gain a great deal. It is worth noting that there is no evidence of significant e-cigarettes use among non-smokers or by or those would otherwise have never smoked. Your editorial follows the established pattern of prohibitionist public health activists of focusing on minor or implausible risks for which no evidence exists in reality, while ignoring or diminishing the huge potential benefits that are real and visible from adopting e-cigarettes.

Negativity about the tobacco industry is inevitable and appropriate, but there has long been scope for a different business model to emerge [8]. Many in the public health community regard the industry as, a priori, capable only of causing harm as they strive to make money [9]. But this idea is not universally accepted, and there are different ways of looking at the role of tobacco companies when it comes to ‘harm reduction’ [10]. These companies are primarily in a market for legal recreational nicotine. For the incumbent tobacco businesses, the rise of the e-cigarette is deeply threatening to their long established product lines. For good reason this is seen as a ‘Kodak moment’, echoing the challenge to the redoubtable photography firm as it faced the digital camera revolution, but ultimately failed [11]. Big Tobacco is moving into e-cigarettes because it has to, not least because its customers may want nicotine, but increasingly they don’t want the smoke that goes with it. Meeting that changing demand happens to be a very positive one for public health, and it could ultimately change the tobacco industry itself for the better.

The tobacco control community has ideas for what it calls the ‘endgame’ for tobacco, but these tend to rely on massive state intervention and public acquiescence [12]. A more plausible and much less coercive endgame would include a transformation of the recreational nicotine market from a harmful to a harmless delivery system. The tobacco industry is potentially a prime mover in causing that to happen and it needs a kind of ‘vigilant encouragement’ in that direction.

Finally, you speak approvingly of Michael Bloomberg’s public health initiatives and link these to gains in life expectancy in New York. But your approval seems to derive mainly from the former Mayor’s willingness (‘courage’ as you put it) to apply coercive prohibitions, not from real evidence of their success in improving health outcomes. I hope there be a BMJ special edition setting out the evidence for the effectiveness of these measures in improving life expectancy in New York. If Bloomberg’s measures are all you say, then many cities will surely wish to follow. But as far as I am aware the evidence of their effectiveness is very thin. It would be a shame if his enthusiasm for banning e-cigarette use meant that fewer people switched from smoking to vaping. In this event, his ban will support continued smoking, and in doing so, it will cause additional unnecessary real-world deaths.

[1] See examples at Bates, CD. Where is the empathy? Where is the humility? []

[2] Professor Robert West, Trends in Electronic Cigarette Use in England. Presentation to Electronic Cigarette Summit 12 November 2013[

[3] Eurobarometer 2012, Attitudes of Europeans to Tobacco, May 2012 [

[4] Jarvis M, Hajek P, Britton J, Stimson G, Polosa R, Fagerström KO, Kunze M, Lund KE, Le Houezec J, Axéll T, Ramström R, Bates C. Letter to Secretary of State for Health, Tobacco Products Directive and snus, 7 October 2013. []

[5] Axéll T, Borland R, Britton J, Fagerström K, Foulds J, Gartner C, Hughes J, Jarvis M, Kozlowski L, Kunze M, Le Houezec J, Lund K, McNeill, Ramström L, Sweanor D. (2011) Letter to Commissioner Dalli, The advancement of the scientific basis for the EU Tobacco Products Directive. []

[6] Minutes of meeting between Commissioner Dalli and health NGOs, 29 February 2012 []

[7] Andrade MD ,Hastings G ,Angus K. Promotion of electronic cigarettes: tobacco marketing reinvented?. BMJ 2013;347:f7473

[8] Bates C. What is the future for the tobacco industry? Tob Control 2000;9:237–8.

[9] Gilmore AB, Peeters S, Understanding corporations to inform public health policy: the example of tobacco industry interests in harm reduction and reduced risk products Lancet 2013:382:S14

[10] Britton J. Electronic cigarettes. Thorax 2013;68:904–5.

[11] The Economist, Kodak moment, 28 September 2013 [

[12] Warner KE, The Tobacco Endgame, Tob Control 2013;22:S1

Competing interests: No competing interests

09 January 2014
Clive Bates
4 Pentney Road