Electronic Cigarette Consumer Association UK

Tobacco Harm Reduction in the UK

Many people wish to stop smoking due to the possible impact on their health or that of their close families [1]. The problem is that it is a complex and powerfully-compelling habit, and not only that - many people find their lives are improved by smoking due to its beneficial effects on stress, cognitive ability and depression, a fact supported by many research projects [2]. This means there are two strong reasons for people to continue to smoke: it is very hard to stop, and some people's lives are better while smoking.

Tobacco Harm Reduction is about finding acceptable solutions to this conundrum. It involves the substitution of a less-harmful replacement for the original product. Since the principal danger is in the smoke, not the nicotine, the object is usually to find a way to supply nicotine without smoke [29].

The consumer purchase of an alternative, less-harmful substitute is the result. This might take the form of smokeless tobacco (e.g. Snus) or an e-cigarette. Harm Reduction involves a consumer purchase decision leading to reduced risk. In this way, an alternative can be employed for permanent use, and for those for whom cessation is either not possible or desirable, an acceptable solution is available.

In some cases Harm Reduction has proved phenomenally successful: Sweden, for example, reduced the number of smokers by circa 40% and the smoking-related death rate by a similar amount, by the widespread use of Snus (Swedish special oral tobacco micro-pouches). The risk of a Snus user is proven by more than 150 clinical trials and large-number surveys involving tens of thousands of people to be roughly the same as a non-smoker - in other words, about the same as quitting totally. The health implication of the difference between switching to Snus and totally quitting is statistically insignificant, as proven by twenty-five years of population-level data - Sweden has the lowest smoking-related mortality in the developed world by a wide margin.

Electronic cigarettes are seen by some professors of medicine who have endorsed them to be potentially even safer than Snus. This would mean that, as e-cigarettes are far more popular than Snus, the number of smokers and the smoking-related death rate will be reduced even more substantially than has been the case in Sweden, as e-cigarette use grows among smokers. By 2013, it is thought that 6% of smokers in the UK and USA will have switched. As this growth continues, the smoking death and disease rate will start to fall dramatically.

As an interesting example of how Harm Reduction has immense practical benefits even in unexpected ways, oral cancer rates in Sweden have fallen dramatically in Sweden over the past ten years, while Snus consumption and use has increased sharply.Sweden already has the lowest male lung cancer rate in Europe, and will soon have the lowest oral cancer rate as well - while having almost double the number of oral tobacco users as smokers.

E-cigarettes are a Clean Nicotine Delivery System, and as such, have about the same health implications as drinking coffee. There is no practical difference between responsible consumption of alcohol, coffee, fatty foods or nicotine. Such consumption habits cannot be described as harmless; but driving or breathing city air probably carries more risk than responsible consumption of these substances.

Tobacco Harm Reduction vs Harm Management

The term 'harm reduction' can be used in its generic form to describe both consumer purchase choice of less-harmful replacements and medical prescription of less-harmful replacements.

Specifically, Harm Reduction refers to a consumer purchase, and Harm Management refers to a medical process. Thus, there are two possible routes:

1. A consumer product purchase decision can be made, and the buyer chooses a reduced-harm product such as Snus or e-cigarettes. The buyer is still using a tobacco product (though in the case of e-cigarettes this is debated), but with a reduced risk profile. They intend to continue use of nicotine (and also, in the case of Snus, the other tobacco alkaloids we call WTAs [31]) without cessation. This is Harm Reduction.

2. A doctor's prescription (or OTC NRTs [3]) can be obtained. Doctors prescribe pure nicotine replacement medicines. The psychoactive drugs which can alternatively be prescribed are not in the harm reduction class. The pure nicotine therapies include skin patches and chewing gum. This is Harm Management because it is a medically-managed process, though it can come under the 'harm reduction' generic terminology. 

The patient is prescribed an NRT or combination of NRTs containing nicotine, the principal (but not the sole) active alkaloid in tobacco. Smoking cessation psychoactive drugs do not, strictly speaking, come under the Harm Management classification as they are a separate type of treatment that does not include any of the ingredients of the original substance.


How effective is Harm Management for smoking?
Not very. Smoking is extremely difficult to quit for many who try.

In terms of the proven success rate for the various methods of cessation or switching (which is the equivalent of cessation when the products have a proven risk equivalence to quitting), the results are:

• 53% for well-organised motivational programmes, such as that of the Allen Carr organisation.
• 40% for Snus, as shown by that reduction in the number of smokers at population level in Sweden.
• 31% for e-cigarettes where every factor was a worst-case option (medical survey).
• About 5% for UK NHS quit smoking services (an estimated figure for the standard 20-month mark measurement, as no figure has ever been published; although the figure might actually be lower than this).

Anecdotally, the success rate is about about 75% for e-cigarettes under ideal conditions (the best equipment, freely available according to user choice, with full mentoring by experts).

The UK's Health Minister said recently (2011) that you can "...double your chances of succeeding in quitting" by the use of pharmacotherapies. From the ignorant and untutored, such a statement could be interpreted as hogwash and piffle. From a doctor, it would qualify as a lie. From an expert, it can be classed as an egregious lie, since lies on this scale lead to loss of life.

Quitting by motivation and support is far more successful, at least in some circumstances [4,5]. For example it is reported that ASH UK had to issue an unreserved apology and had to pay costs when their Director claimed on radio that the 53% success rate claimed by the Allen Carr organisation was false. It turned out that the success rate quoted had been determined by approved trials and published in peer-reviewed journals.

No evidence exists that pharmaceutically-assisted quitting has anything other than a very high failure rate - typically at least 90%. More than 90% of medical patients or those independently taking NRTs will fail to quit smoking, and return to cigarettes. The percentage varies according to various factors, as might be expected. Mentoring and support increases the success rate, but even so there are no results that show any better than a 90% failure rate at 20 months. In fact several research trials give a success rate of just 2% (or even worse [5]).

The exact figures are:
-- Nicotine skin patches and nicotine chewing gum: 2% success rate at 20 months (7% at 6 months) [6].
-- Mentored programs in the UK via the SSS (NHS stop smoking services) using assorted treatments: 15% success rate at 6 months [7]. There is no 20-month figure reported but we know that all other such figures are less than one-third the 6-month percentage at 20 months, so we might guess 5% (at best) [8].

Why is medical management so ineffective?
This is probably due to a number of factors:
1. Tobacco dependence is complex, and attacking just one component - nicotine - is apparently not successful. A failure rate of up to 98% proves this.

2. Smokers may well be equally - or more - dependent on the WTA (whole tobacco alkaloids), or even the added synergens, in tobacco. Individuals differ in their dependence profile, but one thing that can be stated very clearly about tobacco dependence is that it is complex. For some reason, medical treatments have only addressed the nicotine component, whereas we know that there are at least three chemical groups in cigarettes that are potentially addictive (nicotine, WTA, nicotine plus synergens).

3. The physical component of the habit, including (a) the routine, (b) the oral procedure, and (c) inhalation delivery, are strongly associated with the nicotine supply for some smokers.

...and perhaps more beside. Many smokers are in effect self-medicating - they have found a super-efficient way of supplying on demand a natural plant ingredient that is part of their diet in any case [9,10,11], and has strongly beneficial effects in their daily lives. If that substance is removed, their lives suffer. They need more nicotine than is supplied by the diet in order to function correctly. Not only that, they also seem to prefer it delivered via the lungs, in a process they are conditioned to expect to be successful.

Why are e-cigarettes so successful?
An electronic cigarette provides a faithful reproduction of smoking, with most factors very well replicated. E-cigarette use is an alternative method of nicotine supply that may be described as e-smoking, which goes some way to explaining why it is so successful - people feel they are still smoking.

Smokers, on the whole, love e-cigarettes. They dislike NRTs [12]. E-cigarettes work [13], and we can expect that for a country where e-cigarettes are freely available, popular, and widely used, the smoking death rate will fall much lower than even that for Sweden [14] - since smokers seem to prefer e-cigarettes to Snus [15].

The nicotine level can easily be adjusted by the user. This means that exactly the desired result can be achieved. Blood tests show that a level of over 40ng/ml can be achieved if desired, which is around the highest level achieved by a smoker (levels commonly range from 10 to 50 ng/ml).

Only nicotine is supplied by an electronic cigarette or PV (personal vaporiser), and not the WTAs or synergens, but for some reason most people can successfully withdraw from those ingredients fairly quickly when using an e-cigarette. For those who cannot, Snus used in conjunction provides a perfect balance.

A recent development is the availability of WTA-inclusive refill liquids, following the widely successful use of DIY versions. These e-liquids contain tobacco WTAs such as nornicotine, anabatine, anabasine and myosmine as well as nicotine. At least one of these components has been successfully included in medical therapies for the treatment of inflammation and symptoms of Alzheimer's, leading to the conclusion that nicotine is not the only beneficial component of tobacco.

How effective are e-cigarettes for quitting?
If you are asking this question, you have missed the point.

E-cigarettes are not for quitting. They are not sold for the purpose of quitting / cessation [16]. Smokers want a safer alternative they can use with less risk.

When Hon Lik (aka Han Li) invented the electronic cigarette, he wanted to create a way to keep smoking but without the poisons. He succeeded.

The vast majority of e-cig users want to keep smoking but with something that appears to have a much lower risk profile. They have switched to an alternative that is less risky. They may have quit cigarettes [17], but whether they have quit tobacco or not is more a question of semantics than anything else. Apart from the 7% who use zero-nic refills, they have not quit nicotine and do not intend to as it is beneficial to them. Because the risks are extremely low - probably not that dissimilar to coffee - there does not seem to be any pressing need to quit. And of course they may be in the group who cannot function at full effectiveness without it.

There may be a risk to long-term over-consumption of nicotine, but as yet this has not been quantified as any more dangerous than excessive coffee consumption. There is no medical research anywhere that shows nicotine consumption to be any more harmful than coffee consumption. There is, in contrast, a veritable mountain of data that shows long-term nicotine consumption to have very low risks indeed - the 150-plus Snus trials.

Some e-cigarette users will wish to quit all forms of smoking, and will succeed in doing so because anecdotal reports suggest it is easier to quit e-cigarettes than it is to quit tobacco cigarettes. But this is a small percentage of e-cigarette users since the majority wish to keep 'smoking' using a safer alternative.

The overwhelming majority of e-cigarette users do not intend to quit, and questions as to whether electronic cigarettes are efficacious for quitting or not are irrelevant. Use of a Harm Reduction product by definition means that no cessation has occurred. Cessation occurs after the Harm Reduction product has ceased being used - but e-cigarette users typically do not intend to cease use.

Lack of competence among medical professionals
There is a worrying demonstrated lack of competence among medical professionals in this area, especially in the UK. The BMA in particular has shown a remarkable lack of competence in this area:

BMA proclamations

They are clearly many years behind medics in other countries, and the advice they give is not only demonstrably wrong, but dangerous. It is difficult to know if this is due to genuine ignorance, or the result of being financially conflicted; but the publication of materials directly in conflict with medical opinion, which also happens to conflict with government agency advice [33], does not give confidence in their ability. Their willingness to publish fabricated statistics is a pointer to their overall level of competence.

It is perhaps a guide to the general level of knowledge among UK medics in this area. Many do not appreciate that Harm Reduction refers to a consumer-choice continued consumption of the product in a less-harmful form; by definition, it has absolutely nothing to do with cessation. The use of Harm Reduction means that cessation is excluded.

In the area of Tobacco Harm Reduction, it is provably orders of magnitude more effective than any form of medical intervention for the purpose of saving lives. The Swedish Miracle appears to be strongly denied by a group within the UK medical establishment, and one wonders if this might also be a group who depend on pharmaceutical industry funding in one form or another.

If financial motivations are the prime reason for advocacy of one form of action over another, we should be proud of elements within the UK healthcare industry: they have successfully ensured that the UK is one of the most restrictive countries in the world in this area. Consumer choices that would already have saved tens of thousands of lives have been successfully blocked, and more resistance is probably planned. One might almost say that Britain leads the world in this antediluvian attitude, and its rejection of routes that can save orders of magnitude more lives than proven ineffective pharmacotherapies. If one wanted to find people who deny that Sweden has the lowest rate of smoking-related mortality in the developed world by a wide margin, the first place to look would be the UK: incompetence and financial conflicts rule the day here.

Advantages of e-cigarettes

An electronic cigarette is a Clean Nicotine Delivery System - that is, it can supply the nicotine needed, without the harmful materials in tobacco cigarettes.

An examination of the ingredients (of which there has been extensive research) shows that there is nothing that can cause cancer or heart disease. No analysis of the vapor has ever shown any carcinogens above the levels existing in NRTs. No tar or carbon monoxide is present. No combustion takes place, so there is no smoke: the reason for virtually all of the toxic components.

However, the question of lung disease is a relevant one. If it is impossible for an e-cigarette to cause lung cancer, and probably any other kind of cancer, and the likelihood of heart disease is exceptionally low and dependent almost exclusively on long-term over-consumption and abuse of nicotine in conjunction with other powerful indicating factors - what about lung disease?

The refill liquid contains mainly PG and/or VG, flavouring, and nicotine if required. PG is propylene glycol, an excipient that has been studied in detail for 70 years, and has a very large body of documented research with no recorded instance of death or severe harm being caused. It is of course used in asthma inhalers, the nebulisers used by lung transplant patients, and injectable medicines - as well as the disco fog machines that initially caused the choice of material. The alternative material, VG or vegetable glycerine (a misnomer since synthetic glycerine of pharma grade is also used), is in fact recommended for inhalation purposes over PG by some manufacturers. Dow Chemical, who supply it to pharmaceutical companies for inhaled medicines, recommend it for this purpose.

It seems unlikely that materials with 70 years of problem-free data, or those used widely for inhaled medicines, would cause lung disease. PG is also a powerful bactericide and virucide even at low concentrations of the order of 2ppm - it has been used in hospitals for killing airborne pathogens. In one trial, over a period of years and with controls, it was shown to reduce infections in a protected ward by 95%. This included colds and influenza, which are caused by a virus, not bacteria.

The flavourings used in liquid refills are normally approved food flavours such as coffee, caramel and chocolate, plus tobacco extracts for some types (those that replicate tobacco brands). Although it is unlikely that such flavourings could cause widescale disease, no doubt some individuals will prove intolerant to some flavourings.

Nicotine is beneficial in small quantities (i.e. dietary quantities or amounts reasonably larger), and harmless except in very large amounts. No research has ever shown it to be more harmful than coffee when consumed in equivalent amounts. It needs to be repeated that nicotine is a dietary ingredient and everyone everywhere tests positive for it in very small quantities, like many such materials - it is not some form of toxic, unnatural substance. The co-located nutrient and metabolyte nicotinic acid is even a vitamin: vitamin B3 or Niacin. Nicotine itself is not harmful, and is beneficial to some extent to all, and in larger quantities to many. Suggestions that contradict this have no foundation in medical science; and due to the extremely large volume of Snus research, we know exactly what the consequences of ad lib consumption of nicotine over decades are: insignificant.

Drawbacks of e-cigarettes
As the inhalation technique needed for an e-cigarette is different from that used for a tobacco cigarette, beginners often fail to derive full benefit from the device. In particular, a beginner may not receive sufficient nicotine, due to poor purchase decisions, incorrect technique, faulty set-up procedure or choice of refill liquid of too low a strength.

In fact, there is good evidence that a beginner, isolated from expert advice, and thus given no training in how to order the correct hardware or liquid refills, or how to prepare the equipment, or how to use the equipment (since use differs in most ways from cigarette smoking), will receive very little or even no nicotine from an e-cigarette [18]. This shows the importance of advice or support of some kind from the experienced, which would probably hold true for any type of cigarette replacement, alternative or treatment.

It seems particularly true for e-cigarettes though: photos accompanying several research trials of the vapour constituents show the e-cigarette being operated inverted, a mode in which most models cannot possibly work correctly (if at all) since they are a gravity-fed liquid-feed device in which the heater coil must be immersed in order for it to work correctly and which won't work upside-down [19]. If researchers cannot appreciate the basic principles by which the equipment works, it seems likely some users may have issues.

The basic models sold to beginners tend to be low-hassle but with limited performance. This means that the best results may be sacrificed for ease of use. Typically, these models are 'minis': small-format cigarette clone types (i.e. Tier 1 models [20] or first-generation models). Although they are acceptable to first time buyers (and indeed this is their primary if not exclusive function), their performance will not be sufficiently good to satisfy all users - a larger model will be required for many individuals. Polls of experienced users show that only 8% still use a Tier 1 model; 92% upgraded to something that worked better.

E-cigarettes that perform better than the entry-level models tend to be fiddly. This means the overall experience is more similar to pipe smoking than cigarette smoking - some experimentation with variables is required. It means that there is usually a performance vs ease of use trade-off.

However, recent developments in cartomiser technology mean that usability has improved to the point where new buyers can obtain products that work well with little or no user experience needed [30].

It is important to note that minis, first-generation ('1G') models, are obsolete for all purposes now except for new-buyer familiarisation - we are on third-generation ('3G') equipment now, and the performance is so much better that there is no comparison. 1G models are typically small cigarette-clone models, 2G have larger batteries and are the smallest that will provide acceptable performance, or are basic models of the replaceable generic battery type, and 3G (3rd-generation) models are large-battery full digital control models with regulated or variable voltage.

2G and onward are what any performance measurements need to be based on, 1st-generation equipment is obsolete now and only has specific uses:

• New user conversion - new buyers want an e-cigarette that is the same size as a tobacco cigarette, even though this forces them to accept very limited performance
• Low-profile use where limited performance is not an issue.

Second- and third-generation models provide far more vapor - double or treble the volume - and more nicotine if needed. Successful conversion often depends on trouble-free operation and sufficient vapor being available; this is why 1G equipment is obsolete.

Quit smoking - or change to a safer product?

It seems that some people need nicotine in order to function properly. Or perhaps that should read 'more nicotine', since it is part of the diet and everyone tests positive for it [9,10]. For these people, quitting totally does not seem to be the right option.

Nicotine is not the harmful constituent in tobacco smoke, it is the smoke. In fact:
“Nicotine itself is also often conflated with smoking in ways that imply that it causes most or all of the health risks. There is ample evidence that these messages prevent people from learning that the risks from smoking cigarettes come from inhaling the concentrated smoke from burning plant matter. Switching from smoking to a low-risk source of nicotine is so close to being as healthy as quitting that it is hardly worth worrying about the difference.” (Prof. C Phillips, P Bergen) [21]

In practical terms what this means is that if a person drinks tea, coffee, wine or beer then avoidance of nicotine seems a pointless exercise, as the potential for harm is about the same - especially as it means vegetables would have to be avoided. Larger amounts of nicotine than are easily available in the diet should probably be avoided by those who are pregnant, who have heart disease, and those on certain types of medication - but others need not worry too much.

It is also important to note that anyone who consumes coffee, beer, wine or spirits is in no position to lecture others on what they consume - such a position would be the most extreme hypocrisy, and also has no medical basis since no research has ever suggested that responsible nicotine consumption is any more harmful than that of alcohol or coffee.

For those who wish to stop smoking, and for whom there are no negative effects within their daily lives, there appear to be two proven choices of quitting methods with any realistic prospect of success: quit using a very well organised and efficient support group within an organisation that has a recognised success rate such as the Allen Carr organisation (a reported 53% success rate), or switch to Snus. This of course does not include the NHS programme, which has a proven high failure rate that they themselves report (85% failure at 12 months, which will certainly increase to well over 90% at the 20 month standard mark for final measurement of quit attempt success). But for those who suffer too many negative consequences due to an ongoing actual and measureable need for nicotine, Harm Reduction is a far better choice.

We now know that Harm Management quitting (medical management of the process or the use of OTC pharmaceuticals) cannot be described as successful, since around 95% of subjects will return to smoking within 20 months. There is no evidence anywhere that, at the standard 20-month mark for final measurement of smoking status, pharmaceutical interventions have anything other than an appallingly low success rate of around 5% (or worse).

Consumer Harm Reduction is far more effective

Initial, anecdotal reports of e-cigarette conversion success rates are higher than anything previously seen. Since there is no evidence of any potential for harm, the numbers of lives saved will, logically, exceed anything seen so far.

Harm Reduction is proven far more effective both in terms of take-up rates and lives saved, when the data from 25 years of Snus research in Sweden is examined. Harm Reduction specifically means consumer purchase choices that involve a perceived lowering of the buyer's risk profile. Low-alcohol beer, decaff coffee and low-fat foods are all Harm Reduction choices, they are consumer purchase decisions, and they present some form of perceived risk reduction for the buyer. The consumer does not quit the original substance, they change to a safer (in their view) alternative form of the product.

When the product is also confirmed as safer by medical research, this is a clear win - because many more people will succeed in changing to the product if it is widely available than those who try to quit with any form of medical process, and a great many less lives are lost as a result. The data from Sweden is irrefutable since they have the lowest smoking-related death rate in the developed world by a wide margin. In effect it would not matter what the clinical trials report, since the mortality rate is so low in comparison with other countries.

Snus has proven both safe and orders of magnitude more effective than any method involving pharmaceuticals.

Harm Reduction works because the purchases are acceptable to the consumer. The buyer does not cease use of the original product, just the form it takes. These choices may not be as satisfying as the original version, but there is a trade-off in the consumer's mind, with safety winning over 100% product satisfaction, such that a product that has an 80% score being acceptable in the circumstances. Harm reduction is most successful of all when it involves consumer choices as against medical management. Instead of being a resented medical process, it becomes an acceptable consumer choice. Instead of a risk of the patient removing themselves from the medical process, they are a consumer making a preferred choice that is a better long-term risk.

So in the end the answer to the question, "Quit smoking or change?" is: you have around a 5% chance of success with the medical process but a far greater chance of being able to change to a safer alternative - the minimum success rate for e-cigarettes we are aware of is 31% by using first-generation cigarette-clone models with no mentoring - i.e. the worst possible scenario. It is not hard to design a better way to convert to e-cigarettes:

• Use second-generation or later equipment as it works far better
• Use a properly-organised mentoring / support system
• Use Snus or WTA-inclusive refills for those who cannot totally switch with just the e-cigarette, and who may need the WTAs

Such a programme would have a 20-month success rate of at least 60% according to anecdotal results so far (these quote figures of 80% but some leeway must be given for optimism). It is so far ahead of the pharmaceutically-assisted programmes that comparison is pointless.

Therefore if you go for a safer alternative instead - a Harm Reduction choice - your chances of living longer are likely to be increased by several orders of magnitude. We have no long term data for e-cigarette safety compared to smoking, as yet, but if it compares to Snus in any way, the prospects are excellent. A Snus user has the same risk as a non-smoker [22].

Not only that, the smoking rates for any country that fully allows e-cigarettes to be used unrestricted should fall dramatically, since e-cigarettes are more acceptable to consumers than even Snus are compared to pharmaceuticals. If the opinions of the medical experts who have endorsed e-cigarettes are correct, the death rate will fall in proportion [23].

Sweden is the proof: they have the lowest tobacco smoking rate in Europe [24,25,26,27] and the lowest smoking-related mortality rate in the developed world by a wide margin. It works.

In Sweden the number of smokers has reduced to between 12% and 15%, depending on which statistics are used. In the UK it is about 21% - 23% and reducing at a paltry 0.4% to 0.1% per year, depending on the source of the stats.

The tobacco industry in some places reports that cigarette sales are falling by around 3% to 4% per year. This does not align with the reduction in smoking, and probably indicates a rapid growth in sales of black market cigarettes.

In Sweden the death rate dropped dramatically, and is approaching the 40% drop in smoking prevalence there. In the UK there is no measurable reduction.

Which works better: pharma-managed treatments or consumer harm reduction?

Tobacco use reduction

In recent years, the trend has been to try to treat those who wish to cease use of tobacco with pharmaceuticals. Various types have been developed, such as nicotine skin patches, nicotine chewing gum, and drugs such as Chantix (Champix, varenicline). Because health service providers need to be seen to be doing something about the smoking death rate, a situation has arisen where the health service has pushed and promoted the use of these pharmaceuticals - rightly - to treat smoking dependence.

A secondary issue is that because these types of medicines are extremely profitable, what is in effect a money machine has been created: a large movement of funds between suppliers and providers that cannot be stopped. The huge amounts of money involved have inevitably polluted the entire process. The result is that the primary goal of saving lives has been, for all practical purposes, replaced by the need to keep the money flowing and keep the people involved employed.

The big problem with this machine is that pharmaceuticals don't work very well. Independent research frequently shows the success rate of some as about 2% - just a fraction better than the placebo success rate [6].

Although intensive mentoring and combined-drug therapies work better, there is no evidence from any independent research that the success rate for any method involving pharmaceuticals is any better than 10%. The failure rate of any method involving pharmaceutical treatment or medical management of smoking cessation is always 90% to 98%.

No results at the 20-month mark are any better than those given above. At three months, or six months, the results are much better of course. But if the patient eventually relapses - as almost all do - then the process has failed and all the time, money and effort has been wasted.

It can now be seen that the entire process has become more about the money and the jobs than saving lives, since it is obvious that many more lives would be saved by completely abandoning the established process and moving to an entirely Harm Reduction-based (i.e. consumer purchase based) process.

It is time for a paradigm shift in this area of medicine - time for the current medical process to be abandoned and replaced by something that actually works.

Medicine does, after all, change over time; otherwise we would still be using bleeding/cupping and horse manure poultices.

Time to get rid of a little more horse manure, in fact.

Fraud?

If the cost to the country is several hundred million pounds for smoking treatment programmes, which have a final success rate of under 10%, then perhaps somebody is responsible for some sort of scam?

NHS Stop Smoking Services for England cost £84m in 2009-2010 [28].
a) This figure does not include the cost of the pharmaceuticals, which is likely to be nearly the same amount.
b) It is not clear if this figure includes all data from individual doctor's practices, but it may not.
c) To this must be added the similar costs for Scotland, Wales and Northern Ireland.
d) The total cost equals ~£150m for England plus any additional GP / clinic costs plus all costs for all other UK countries - a total likely to approach or exceed £200m.
e) The end cost per NHS England successful quitter at the standard 20-month test mark (which has never been reported for the NHS) will be several thousand £s per patient.

[see #28 for all references]

This is a phenomenal cost, which in itself is simply not acceptable. It doesn't work, it has never worked, it is proven not to work, and it will never work. Add to this, the human cost of the ~95% who will fail due to this programme and return to smoking - which is in fact the real cost.

Up until fairly recently we could honestly say that no intentional scam had taken place - the medical establishment was simply doing the best it could. If it got 5% (or even just 2% as is common) of patients off smoking, then at least some people would not die. Another benefit is that others are not injured by second-hand smoke. The cost was very high by whatever terms it is measured, but it was the lowest cost achievable with current knowledge, four or five years ago.

The trouble is that we now know there are far better methods to use:

-- Ways that work far better
-- Ways that are much more acceptable to the subject
-- Ways that cost less
-- Ways that save a vast amount more lives

We call it Harm Reduction: consumer choice of safer products. It works. The NHS pharmaceutical- based Stop Smoking Services doesn't and never will. By current standards it is fraud: the extraction of money from the taxpayer with a promise of results that are not delivered and will never be delivered; and the routing of that money to those who certainly have not earned it in any way, shape or form.

And furthermore, doctors who subscribe to these procedures are skirting very, very close to negligence:

• The vast majority of their patients are risking death since they will almost all return to smoking
• The treatments are widely known to be virtually useless
• The most effective pharmaceutical treatment, the pschoactive drug Chantix, is proven to be thousands of times more dangerous than e-cigarettes and all but useless by comparison [32]

.....continued in Part 2

Notes

[1] Some sources say one in two smokers will die as a result of illness caused by smoking; some say one in three, some say one in four. A quick 'n dirty analysis of UK statistics seems to indicate 1 in 5, however. It may be one of those figures that cannot be verified - like the number of UK smokers, variously quoted as any number between 19% and 25% of the population.

The 'one in two' figure may originate with the Doll, Peto at al study (links below) but perhaps it is not reasonable to make such an important statement on the basis of just this study. Can another reference can be suggested? Since references generaly quote a figure between 20% and 50% for smokers' mortality, we generally use 33%, as a compromise figure. In our opinion the profession should probably do something about this disagreement, so that a better-accepted figure can be used.

http://www.bmj.com/content/328/7455/1519

http://www.bmj.com/content/early/2003/12/31/bmj.38142.554479.AE.full.pdf+html

http://www.bmj.com/content/1/4877/1451

[2] The positive effects that smoking has for some conditions is probably due to nicotine:

Effects of nicotinic stimulation on cognitive performance
http://www.ncbi.nlm.nih.gov/pubmed/15018837

http://en.wikipedia.org/wiki/Health_benefits_of_smoking

http://www.forces.org/evidence/evid/therap.htm

http://health.howstuffworks.com/wellness/drugs-alcohol/nicotine-health-benefits1.htm

[3] Some NRTs can now be bought without prescription, 'over the counter' or OTC.

One consequence of this is that supply of these medicines is now unrestricted, and they are given to children. In fact they have been distributed in schools, with one recorded adverse event. Of more significance, perhaps, is the fact that instead of the e-cigarette industry being guilty of providing nicotine-containing products to children, a hysterical accusation for which no evidence has ever been provided, instead agencies are distributing nicotine products to children - an undisputed fact and one with noted consequences.

[4] Surveys of ex-smokers always find that the vast majority quit without any aids at all. The percentage varies between 70% and 80%, but on average, 75% say they quit cold turkey. The percentage who report they quit with pharma assistance is very small.

Resources suggesting that chemically-unassisted tobacco cessation is more successful than popularly believed:
http://whyquit.com/pr/123106.html

Long term success of short smoking cessation seminars supported by occupational health care

Smoking status of Australian general practice patients and their attempts to quit
http://www.sciencedirect.com/science/article/pii/S0306460305001590

Smoking cessation at the workplace: 1 year success of short seminars
http://www.mendeley.com/research/smoking-cessation-workplace-1-year-success-short-seminars/

[5] A presentation by D. Atherton, with a list of links and references, including the ASH vs Allen Carr org details.
http://daveatherton.wordpress.com/2011/04/24/is-smoking-a-disease-or-a-habit/

[6] Effectiveness ..... of NRT assisted reduction to stop smoking.....
http://www.bmj.com/content/338/bmj.b1024.full

7% remain cigarette free after 6 months, 2% remain cigarette free after 20 months (a 98% relapse rate).

[7] There is no 20-month success rate figure reported for the UK NHS quit smoking programme. Other 20-month figures are always less than one-third the 6-month figure (typically 7% at 6 months, 2% at 20 months), so 15% at 12 months dropping to 6% at 20 months is a reasonable guess that errs on the side of caution (it could be lower at 4% or 5%). The single and only reason why we quote 10% as the best-possible success rate for pharma-based treatments is because there is always a possibility - a very, very small one - that the UK managed programme results may not be as bad as all other results everywhere else in the world. Realistically we should quote 7% as the best possible success rate for any pharma-based treatment, as that is what the research tells us.

Our bet is that a 20-month figure for the NHS programme will never be published.

[8] A meta-analysis of the efficacy of OTC nicotine replacement
http://tc.bmjjournals.com/cgi/content/full/12/1/21?ijkey=5.ko5/Oz4yutl

7% success rate (cigarette free) after 6 months (a 93% relapse rate).
"This result is similar to that obtained with prescriptions."

[9] The Nicotine Content of Common Vegetables
http://www.nejm.org/doi/full/10.1056/NEJM199308053290619

The CDC in the US tested 800 people, a mix of smokers and non-smokers, and all tested positive for nicotine. A standard nicotine test was given (the urinary test for cotinine).

Nicotine is of course part of the general diet, as it is an ingredient in many vegetables. Everyone tests positive for nicotine or its metabolytes in the blood, unless they eat no vegetables. One form of it is even a vitamin - Vitamin B3 or niacin (nicotinic acid vitamin). Nicotine, like other similar materials and vitamins like Vitamin D, is not harmful except in overdose.

[10] Nicotine concentrations in urine and saliva of smokers and non-smokers
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497991/pdf/bmjcred00600-0012.pdf

A 1982 study of nicotine concentrations in urine and saliva of 136 smokers and non-smokers, all of whom tested positive (GC nicotine assay). This study is famous for the fact the academics did not realise that nicotine is part of the diet, and therefore assumed that everyone is somehow exposed to tobacco smoke. Just another indication that nutrition was never seen as part of mainstream medicine.

[11] It is necessary to eat only 10 grams of eggplant / aubergine or 19 grams of pureed tomato to receive the same amount of nicotine that a passive smoker would receive by breathing in smoke-laden air for 3 hours (1 microgram of nicotine). This means a portion of e.g. eggplant (100 grams) provides the same amount of nicotine a passive smoker in a smoky room would receive in 30 hours.
http://www.nejm.org/doi/full/10.1056/NEJM199308053290619

[12] A commentary on the choice of quitting with pharmaceuticals or instead using a reduced-risk alternative, from the perspective of an average person. Assuming that e-cigarette use entails reduced risk, this is a compelling argument.
http://www.youtube.com/watch?v=dFQm2G4mz3w

[13] The most common questions asked of an e-cigarette user are, "Is that an e-cigarette? Does it work?".

The answers are yes, and yes. They do work: that is, they faithfully replicate smoking, they feel like smoking, they supply as much nicotine as you need, they remove the need to to smoke a tobacco cigarette; and they are entirely satisfactory for the purpose: continuing to smoke but without the same level of danger.

[14] Snus is the highly successful smokeless tobacco product popular in Sweden. As a direct result of its use, Sweden has the lowest smoking-related mortality rate in the developed world, the lowest rate of smoking in Europe (said to be below 15% at 2011), and the lowest male cancer death rate in Europe. The oral cancer rate is also falling and will soon be the lowest in the EU - an unfortunate statistic for the liars and propagandists who say that oral cancer results from all oral tobacco use.

[15] E-cigarette use has grown by about 500% per year in the UK from 2006 - 2011, and at a much higher rate than this in the US [ http://www.eccauk.org/index.php/uk-sitrep.html ]. Snus uptake has never been shown to rival this growth rate.

[16] Because the fastest way to sell e-cigarettes is to tell people they can quit with them (some statistics report that up to half of all smokers think about quitting in any given year), many rogue traders do sell e-cigarettes as quitting aids. They are particularly poor for this since people just keep on using them - as that is their purpose. They are a harm reduction tool not a quitting tool. No rogue traders of this type can register with any trade association or respected community resource. To view lists of responsible traders who adhere to acceptable marketing standards, it is necessary to go to the national trade association or community-vetted lists such as those on a large forum.

[17] E-cigarette users usually cease use of tobacco cigarettes - but this process can take anywhere from a day to a year. Because of this, no truthful blanket statement can be made about 'most' e-cig users, it has to be qualified by whether they are new users or long-term users. Most new users will still be cigarette smokers, most long-term users will not be.

[18] A Clinical Laboratory Model for Evaluating the Acute Effects of Electronic “Cigarettes”......
Eissenberg and Vansickel 2010
http://www.e-cigarette-forum.com/forum/pdf/vansickel-eissenberg-ecigarette-clinical-trial-2010.pdf

Beginners with new equipment managed by researchers who were also beginners received zero or very little nicotine. In contrast, experienced users may obtain sufficient to reach 40 ng/ml blood plasma nicotine level or higher, as desired - in fact, as shown by the same researchers' next trial when correcting their earlier mistakes.

[19] E-cigarette vapour research PDFs
http://www.e-cigarette-forum.com/forum/technical-research/149160-analysis-electronic-cigarette-vapor.html

[20] Tier 1, Tier 2 and Tier 3 models explained:
http://www.eccauk.org/index.php/ecca-library/14-classification-of-ecigarettes.html

[21] Tobacco – the greatest untapped potential for harm reduction
http://tobaccoharmreduction.org/thr2010ahi.pdf
-- p25

[22] Assessment of Swedish Snus for tobacco harm reduction: an epidemiological modelling study
http://www.ncbi.nlm.nih.gov/pubmed/17498798

Snus users in Sweden have the same risk as non-smokers. That is to say, the same risk as smokers who have totally quit, but not as low as never-smokers.

There is no statistically significant difference in health outcomes between those who quit totally and those who switch to Snus.

[23] Snus contains the same amount of carcinogens as NRT nicotine skin patches and e-cigarettes: a minuscule amount, which is locked in to the nicotine and cannot be removed except possibly by expensive further processing - which is unnecessary, since we have two and a half decades of research that show Snus users don't get any form of cancer more often than non-smokers; and because skin patches are licensed as safe. E-cigarettes therefore have the same cancer risk, i.e. essentially none, which is why Dr Laugesen said, "It is impossible for e-cigarettes to cause lung cancer".

[24] http://www.who.int/tobacco/en/atlas5.pdf

[25] Should the European Union lift the ban on Snus?
http://www.ncbi.nlm.nih.gov/pubmed/12930202

"Sweden was the only country in Europe to reach the World Health Organization's goal of less than 20% daily smoking prevalence among adults by year 2000."
"19% per cent of adult men and 1% of women are daily Snus users and the trend is increasing [2003]."

At Q3 2011 Sweden is variously reported to have a smoking prevalence figure of 15% to as low as 12%, which exlains why their tobacco-related morbidity and mortality figures are so much better than any other EU country (or any other in the developed world).

[26] The burden of mortality from smoking: Comparing Sweden with other countries in the European Union
http://www.ihra.net/files/2011/07/13/Rodu_-_Burden_of_Mortality.pdf

Sweden has half the smoking prevalence of the EU average, for men under 65.
The study shows that the low prevalence of smoking among men in Sweden, if adopted throughout the EU, would result in a 40% reduction in smoking-related mortality.
"The prevalence of tobacco use among Swedish men (Snus use 20%, smoking 19%) is the same as the prevalence of smoking among men throughout  the  EU (40%). But, because Snus use produces a very low risk for cardiovascular diseases [ref. removed] and no risk for pulmonary diseases and for oral or other cancers [refs. removed], there is no demonstrable incremental burden of mortality among Swedish men who use Snus."

[27] European Union policy on smokeless tobacco: a statement in favour of evidence based regulation for public health
http://www.ihra.net/files/2011/07/13/Bates_-_EU_Statement.pdf

"[smokeless tobacco] is an important reason why Sweden has the lowest rates of tobacco related disease in Europe."
"Sweden has the lowest levels of tobacco-related mortality in the developed world by some distance - approximately half the tobacco related mortality of the rest of the EU."

[28] See - NHS Quit Smoking: Massive Fail
http://www.eccauk.org/index.php/nhs-quit-smoking-fail.html

[29] "Harm reduction is any program or policy designed to reduce drug-related harm without requiring the cessation of drug use." This separates harm reduction clearly from zero tolerance approaches to drug use (or cessation). Source:
http://www.camh.net/Public_policy/Public_policy_papers/harmreductionbackground.html

[30] The new third-generation cartos such as the dual-coil and bottom-coil models work well from the start, needing no user input for excellent performance (full vapor production and nicotine supply). However, these end fittings can only be used on mid-size models or larger (devices that are bigger than the beginners' mini models), as they draw too much current for the tiny first-generation batteries.

[31] Tobacco contains several alkaloids with effects on the human body. These whole tobacco alkaloids or WTAs include nornicotine, anabatine, anabasine and myosmine as well as nicotine.

[32] E-cigarettes have been used by millions of people, worldwide, for many years (since 2006). There are zero reports of mortality. There are zero reports of morbidity (serious harm). In fact this safety profile could not even be achieved by aspirin.

Chantix is reported in several clinical trials to cause a heart attack in 1 in 30 patients (one trial says more frequently). It causes severe depression and psychotic events for a significant number of patients. It is responsible for suicides and murders; and violent incidents in uncounted numbers. As an example of the scale of the issue, just in the USA, just in 2010, it is believed to have caused 62,500 heart attacks, several suicides, dozens of attempted suicides, and hundreds of violent attacks on others.

In the same timescale that e-cigarettes have been widely used, Chantix is responsible for ruining uncountable thousands of lives - perhaps over a hundred thousand lives are involved. E-cigarette use has resulted in no reported mortality or morbity.

Chantix is thousands of times more dangerous than e-cigarettes.

[33] The MHRA have stated that the use of e-cigarettes can legitimately be described as 'less harmful than smoking' since that is current medical opinion (i.e. the opinion of the experts in the area such as Profs. Siegel, Rodu, Phillips etc.); and that nicotine is 'a very safe drug'. While we would not advise that anyone take much notice of government agencies with such obvious conflicts of interest as the MHRA, it might appear that in this case the BMA, being in some ways apparently a similar organisation, could perhaps take note.