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At the age of 85 many smokers would probably shrug their shoulders when told that stopping smoking would be a benefit to them. Many smokers who reach that age have been smoking, in one form or another, for decades and feel it is too late to stop.

As a smoker of 69 years, one man, after being diagnosed with borderline chronic obstructive pulmonary disease in 2010 decided to at least try to minimise the number of cigarettes he smoked. Over the course of two years, Terry Walker reduced his cigarette smoking from 10 per day to just 2.

The headline statistics from the annual ASH survey on vaping appear great at first glance. Vapers now number 2.9 million in the UK and for the first time ex smokers outnumber current smokers. Is this news really all it's cracked up to be though?

The NNA legal case is the first time that a ‘right to health’ argument has been used to challenge a bad tobacco control law. We hope that this example might be a springboard for challenges in other countries.

NNA’s case to the European Court of Justice is based on EU law and the EU Charter of Fundamental Rights (CFR) [1]. Our argument is that the ban on snus is disproportionate, and that it is contrary to the human right to health. Given the evidence that snus is substantially safer than smoking cigarettes, and that it protects against smoking, it is both unethical and contrary to EU law to deny access to this product.

NNA supports the idea of ‘tobacco harm reduction’ as it is often formulated, in offering smokers and would-be smokers a low risk alternative to smoking. It is as an approach that is preferable to an abstinence only strategy, which is in effect a ‘quit or die’ approach.

NNA also supports the idea that many people like using nicotine and thus – especially if lower risk forms of nicotine are available - there must be major limitations on the ability of the state to interfere with that choice. Tobacco harm reduction recognises that many people find the use of nicotine pleasurable. This is reflected in our arguments that the ban on snus is contrary to the principles of autonomy and choice that flow from Articles 1 and 7 of the Charter of Fundamental Rights of the European Union (CFR).

Rights to health

Our thinking is as follows.

European states are obliged to further the health of their citizens. The preamble to the European Social Charter [2] states that: ’Everyone has the right to benefit from any measures enabling him to enjoy the highest possible standard of health attainable’ and Article 11 requires Parties to take measures to prevent disease and to encourage individual responsibility in matters of health.

Moreover, all EU law must take into account ‘health protection’. Facilitating a high level of health protection is required under Title XIV of the Treaty of Lisbon that ‘A high level of human health protection shall be ensured in the definition and implementation of all Union policies and activities’. A high level of health protection is relevant to all EU legislation including the Tobacco Products Directive. We have argued in our submission to the High Court and the European Court of Justice that health protection includes not only protection from health threats but also includes enabling people to make choices that help them avoid ill-health.

We thus base our argument on an interpretation of Article 35 of the CFR that a high level of health protection must allow access to snus.

A similar argument may be made on the basis of other international treaty obligations.

The relevant obligation is Article 12 of the International Covenant on Economic, Social and Cultural Rights [3], which has been ratified by 165 countries including all EU states. Article 12 recognizes: ‘the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’ and that States Parties must take steps regarding ‘the prevention, treatment and control of epidemic, endemic, occupational and other diseases.’ This has been interpreted by the UN Special Rapporteur on the Right to Health to include access to harm reduction resources for people who use drugs [4]. We similarly argue that Article 12 includes access to tobacco harm reduction resources, ie safer nicotine products.

Tobacco harm reduction is consistent with obligations in the international treaty on tobacco control. All European Union states are signatories to the Framework Convention on Tobacco Control (FCTC), the international health treaty that aims to reduce the use of tobacco [5]. The preamble to the FCTC notes obligations (as mentioned above) under the Article 12 of the International Covenant on Economic, Social and Cultural Rights. Moreover Article 1d of the FCTC specifically refers to harm reduction as one of the defining strategies of tobacco control, which is: ‘a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke’.

As mentioned above the European Social Charter requires states to encourage individual responsibility in matters of health. This view links to a basic principle of public health, which is one of creating the conditions in which people can lead healthier lives. In particular, as stated in the constitution of the World Health Organisation [6], that: ‘Informed opinion and active co-operation on the part of the public are of the utmost importance in the improvement of the health of the people.’ [6]  Empowering individuals and communities to take control of their health is a fundamental principle of public health, as set out in the Ottawa Charter on Health Promotion [7].

Tobacco harm reduction is consistent with the broad public health aim of enabling people to take action to reduce risks to their health. They cannot do that unless they have access to the resources that help them do this. That is why a ban on snus is inconsistent with helping people to lead healthier lives. Snus has to be legalised because snus saves lives.

Gerry Stimson
Chair, New Nicotine Alliance

[1] Charter of Fundamental Rights of the European Union (2000/C 364/01)

[2] European Social Charter https://www.coe.int/en/web/conventions/full-list/-/conventions/rms/090000168007cf93

[3] http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx

[4] Open Letter by the Special Rapporteur on the right of everyone to the highest attainable standard of mental and physical health, Dainius Pūras, in the context of the preparations for the UN General Assembly Special Session on the Drug Problem (UNGASS), which will take place in New York in April 2016. http://www.ohchr.org/Documents/Issues/Health/SRLetterUNGASS7Dec2015.pdf

[5] Framework Convention on Tobacco Control http://www.who.int/fctc/text_download/en/

[6] Constitution of the World Health Organisation http://www.who.int/governance/eb/who_constitution_en.pdf

[7] Ottawa Charter on Health Promotion. World Health Organization 1986. http://www.who.int/healthpromotion/conferences/previous/ottawa/en/  

 

 

More from the NNA on snus:

Leading experts implore the Swedish Govt to back Snus at COP7

Snus facts

NNA goes to the High Court to challenge the ban on snus

Snus ban challenge, NNA media releases, 26th January 2017

Update on the challenge to the ban on snus – next step, the European Court of Justice 

NNA snus ban challenge - update May 2017

NNA snus ban challenge - the legal case

 

NNA contends that snus fulfils the criteria for a tobacco harm reduction product and hence should be available in the UK. The legal ban on snus denies smokers of the choice of a much safer nicotine product than cigarettes.

The introduction of snus into the United Kingdom would form part of a coherent strategy of tobacco harm reduction that help people avoid smoking. The current scientific evidence, and the fact that Sweden, where snus is used, now has the lowest lung cancer and tobacco-related mortality in Europe, indicates that snus is a suitable and appropriate product for individuals who are seeking to avoid smoking and other combustible tobacco products.

The rapid rise in the popularity of electronic cigarettes, a grass roots consumer driven phenomenon, shows that many smokers want to avoid smoking-related harms. There is the potential to reduce smoking when acceptable products are available to consumers; such uptake being at no cost to public funds.

The NNA submits that the ban on snus is disproportionate given the low risk of snus compared with other nicotine products. It is an unsuitable means by which to achieve the aim of public health protection because it removes from consumers the option to use a safer nicotine product.

NNA also contends that the ban on snus infringes the human right to health. The availability of snus is an aspect of personal health and personal autonomy by which consumers can avoid the health hazards of smoking. The ban on tobacco for oral use limits smokers’ choice of safer alternatives, by excluding a product that is significantly less harmful to health than cigarettes. The NNA therefore submits that the ban on snus engages issues under European law, in particular those articles in the Charter of Fundamental Rights of the European Union (CFR) that protect autonomy and choice - Articles 1 (human dignity), Article 7 (respect for private and family life) and Article 35 (health care).

Human dignity

Article 1 of the CFR is an overall obligation to respect human rights, and protects ‘human dignity’. The issue of dignity is linked to personal autonomy: a principle by which individuals make choices on the conduct of their life, which presupposes a range of choices.

Respect for private and family life

Article 7 on ‘respect for private and family life’ is a broad-ranging right that is often closely connected with other rights including autonomy such as freedom of religion, freedom of expression, freedom of association and the right to respect for property. Article 7 has been held to apply to issues of quality of life, self- determination, a right to establish relationships, self-identity, choices in relation to medical treatments to prolong life, and decisions on parenthood by insemination techniques.

Health protection

The EU Charter of Fundamental Rights stipulates in Article 35 that a high level of human health protection shall be ensured in the definition and implementation of all the Union's policies and activities. NNA argues that the EU legislators based the law on a limited understanding of ‘health protection’ in violation of Article 35. By banning tobacco for oral use, the EU prevents access to a product that significantly reduces harm to consumers as compared to cigarettes. The EU legislators, we believe, took a narrow definition of ‘health protection’ to mean protection from products, whereas it should have taken a broader public health definition to include making it possible for people to take action to avoid ill-health through the choices they make.


Further information

The NNA submission to the High Court can be found here, along with supporting expert and witness statements from Gerry Stimson, Karl Lund, Louise Ross and Judy Gibson.

 

More from the NNA on snus:

Leading experts implore the Swedish Govt to back Snus at COP7

Snus facts

NNA goes to the High Court to challenge the ban on snus

Snus ban challenge, NNA media releases, 26th January 2017

Update on the challenge to the ban on snus – next step, the European Court of Justice 

NNA snus ban challenge - update May 2017

Snus and the right to health

European Court of Justice sends legal arguments out for comment

More progress with our case against the ban on snus: the European Court of Justice has now sent the legal arguments out for comment.

In January the High Court in London ruled that Swedish Match and NNA could take their challenge against the UK and EU ban on snus to the European Court of Justice, in Luxembourg.

The documents setting out the legal arguments were agreed between Swedish Match, the UK Department of Health (as defendant) and NNA, approved by the High Court and sent to the European Court of Justice. You can view them here

This first stage is in itself a major success: there are few referrals to the ECJ, and even fewer involving an NGO such as NNA.

The ECJ has now requested comments on the legal issues (see below).

The Swedish Match legal challenge against the ban on snus

Swedish Match – the main manufacturer of Swedish snus – brought the challenge in the UK High Court. Their legal argument is that the law discriminates against snus compared with cigarettes and with lower risk nicotine products, that the ban is disproportionate, is against the EU principle of subsidiarity in removing national regulatory discretion, breaches the duty to give reasons for the ban, and is an unjustified restriction on the free movement of goods.

The NNA legal challenge against the ban on snus

NNA is acting as a third party in the public interest – in legal terms it is an independent ‘intervenor’.

NNA argues that the ban on snus is (a) disproportionate in that it is incommensurate given the low risk of snus compared other products on the market, and (b) contravenes the right under EU law to a high level of health protection.

Significantly, for the first time in a challenge against UK (and EU) tobacco legislation, NNA argues that the ban infringes human rights. NNA argues that the ban contravenes the EU Charter of the Fundamental Rights with respect to Art 1 on ‘human dignity’, Art 7 on ‘respect for private and family life’, and Art 35 on ‘health care’.

Art 35 stipulates that a high level of human health protection shall be ensured in the EU policies and activities. NNA argues that the snus ban is wrong as it prevents smokers from having access to a safer product and is an unsuitable means for achieving a high level of health protection. We consider that the EU legislators misinterpret health protection as meaning only protection from risks from products, whereas it should have considered a product such as snus in helping people to protect themselves from risks through the choices they can make to avoid smoking.

See here for more details of NNA’s legal case and the documents filed in the High Court.

Progress with the case

The High Court agreed on Jan 26th 2017 that there was a case for a review of the legislation. NNA’s request to be joined to the case was allowed by the High Court.

Because the UK law – the Tobacco and Related Products Regulations 2016 – is based on the EU Tobacco Products Directive 2014, the case was referred by the High Court to the European Court of Justice. 

The ECJ has initiated the first steps in the legal review (case C151/17).

The ECJ has now sent out the case for comment to EU member states, the European Commission, Parliament and Council, and EFTA states. All these parties are able to make a submission to the ECJ commenting on the legal issues that we have raised: their comments have to be received by ECJ by 7th July.

When comments have been received back they will be reviewed by the court. It is likely that the actual case will be heard in Luxembourg at the end of the year or the beginning of next year.

Implications of the case

  • The ECJ ruling will apply across the EU, not just the UK
  • Referrals to the ECJ are uncommon – to get this far is a significant achievement for an NGO. 
  • For the first time a ‘right to health argument’ has been lodged as a challenge to tobacco control legislation.


For more details of the argument that the ban on snus infringes the right to health see here

Watch this space!

 

European Court of Justice letter

 Preliminary reference letter

 

High Court letter

 High Court letter with ECJ stamp

 

More from the NNA on snus:

Leading experts implore the Swedish Govt to back Snus at COP7

Snus facts

NNA goes to the High Court to challenge the ban on snus

Snus ban challenge, NNA media releases, 26th January 2017

Update on the challenge to the ban on snus – next step, the European Court of Justice

NNA snus ban challenge - the legal case 

Snus and the right to health

 

NNA calls on UK parties to repeal arbitrary restrictions on e-cigarettes and snus

We have written to the major UK political parties to urge them to include this in their election manifestos:

“We will help Britain’s 9 million smokers switch to healthier alternatives by removing unnecessary restrictions on e-cigarette advertising, tank and refill sizes, strength of liquids, and by ending the ban on snus as soon as we have left the EU. “

However, a lot more pressure is needed. The parties need to know that vapers are voters who are unhappy with the TPD.

Please write to your representative. You can use the Write to Them website to find your MP, MSP or AM and to email them too. Contact us at This email address is being protected from spambots. You need JavaScript enabled to view it. or @NNAlliance on Twitter to let us know how you get on.

This is what we sent to the parties (along with the manifesto wording, above):

Brexit removes the excuse for political parties to avoid reforming the worst elements of current anti-smoking policies many of which come into force on Saturday 20 May.

Particular anger among the 2.8 million UK e-cigarette users has been caused by the EU's arbitrary restrictions on their devices which have no benefit but which make them less convenient to use. These include maximum tank and refill sizes and a much reduced limit on the maximum concentration of nicotine in e-liquid consumers can purchase. Disproportionate restrictions on e-cigarette advertising were introduced in May 2016.

Also of deep concern is the ban on the Swedish smoking substitute snus. As the New Scientist reported in March this product is the key to Sweden’s huge lead in the EU in reducing smoking. The Spectator wrote that “if we want to benefit from Brexit the first thing that we should do is make snus legal”.

E-cigarettes and snus help prevent smoking and smoking-related disease at no cost to the exchequer.

 

The UK election offers a golden opportunity to encourage legislative change.  Don’t waste this chance.


NNA will be at Vape Jam next weekend and we would love to see you there. You can find us at stand G58, along with INNCO and ViP. Dave Dorn (NNA) and Judy Gibson (INNCO) will be giving presentations so look out for those too.

The Vape Jam organisers, Amir Saeed and Maria Borissova, are, for the second year running, donating all the proceeds of the raffle to NNA. We will be selling the raffle tickets from our stand. We hope this will help to spread the word to a much wider audience, as well as raise much needed funds for the NNA. We are very thankful to Amir and Maria for their generosity.

We’ll be collecting NNA Supporter sign ups so please encourage anyone who hasn’t already signed up to come along and do so. The more supporters we have the louder our voice.

We are selling these silicone NNA branded 18650 battery sleeves / condoms from the stand: attractive, useful and consistent with the harm reduction theme! We have battery safety leaflets to hand out too; many thanks to e-cigarette direct for supplying those.  

 battery condoms

And these bags, perfect for carting about all the freebies you’ve picked up over the day:

 

Bag 2 colour
And we'll be wearing these beautiful polo shirts, very kindly ordered and paid for by vapers.org.uk:

 

So, if you go to Vape Jam please do stop by for a chat and a sit down (no need to buy a raffle ticket, etc!). We’d really welcome an opportunity to discuss the issues we are all facing - that’s actually the whole point of us being there.

NNA has come a very long way in two short years and we have thoroughly earned our reputation as a “go to” organisation on tobacco harm reduction. Now we need your help to achieve even more. We have never asked for money before but we need to now.  

We take every opportunity to represent the interests of those who seek safer methods of nicotine use. This includes working with the media, making submissions to governments here and abroad, responding to consultations, challenging rules that make life harder for consumers, speaking at events and working with scientists and regulators. All this costs money and we depend entirely on voluntary contributions.  We would like to thank everyone who has given to us in the past, your support has enabled us to achieve remarkable things.  

Our Trustees and Associates have worked really hard to get NNA this far and, until now, all of NNA’s work has been done by volunteers. We have recently appointed a part-time administrator to ease some of the pressure on our Trustees and to enable our charity to grow.  

Every week there are new challenges: yet more questionable science, threats of creeping prohibition and individuals and organisations that want to sow doubts and fears. We need resources to counter these.

If you support NNA’s aims and like what we do please help to fund our work. Any amount you can spare will be put to very good use. If you are a UK taxpayer please also consider signing up to Gift Aid to increase your donation by 25%. Gift Aid applies to past donations too so please sign up if you have donated to us before, even if you cannot give this time.
 
Also, please get in touch if you can help with fundraising for us, for example if you have an item we could auction, or you’d like to organise an event to raise funds. You can email us at This email address is being protected from spambots. You need JavaScript enabled to view it. or contact @NNAlliance via Twitter.  
 
 
You can donate to NNA here via PayPal, credit or debit card, bank transfer, or cheque.  Or simply text NNAJ17 + donation amount to 70070.
Every contribution helps.
 
In case you missed it, the round up of NNA activities in 2016 is here and you can read about our exciting campaign to get snus legalised here.  
 
 

 UKNSCC 2015

                 

 

 



 

 

 

 

Guest blog from Rhydian Mann, NNA Associate and Welsh Campaign Manager at Vapers in Power  

For all of you out there who know what my day job, is this piece won’t surprise you at all. For those who followed the development of the Tobacco Products Directive (TPD) 2014 into the UK’s transposed version, the Tobacco and Related Products Regulations (TRPR) 2016, this piece will be even less of a surprise.

For everyone else, well, this could be both an education and a shock!

Today, as part of my job, I met with two local Trading Standards Officers( aka TSO’s) in Swansea to discuss some of the“finer” points of TRPR compliance. Sorry, I can’t divulge the actual outcome because I could get fired BUT here are some of the knowledge bombs that came out of it:

1 Local Trading Standards have had no training in TRPR enforcement.
Yes, you read that right. I bluntly asked one of the TSOs if they have had any training or guidance on what to look for regarding compliant and non-compliant packaging for e-liquids. One of the senior TSOs said they have not received anything from the Chartered Trading Standards Institute, the body which provides training for TSOs across the country in any consumer product or consumer service provided to the public. I even rang the CTSI, earlier in the week, to see if they have any enforcement guidance and the best they could do was to pass my inquiry onto someone that specialises in “TOBACCO CONTROL”

This is a very scary thought indeed! This indicates that local TSO’s, when visiting an e-liquid manufacturer or a vape shop, are relying on the text of the TRPR itself and their own interpretation of it. Are the MHRA (the so called “competent authority”) and the Department of Health saying “just get on with it” to local council Trading Standards departments?

2 Do you need a microscope with that?
Anyone who has been hunting for TPD compliant e-liquid products may have seen some bottles labels in miniscule writing! Are some manufacturers crazy? How can any consumer use a product safely when the lettering is even smaller than this:
 
THIS IS ACTUALLY REALLY SMALL!!!
 
I have seen some labelling text as small as 2pt, made tiny so the manufacturer can squeeze in all the silly required information. Sadly, not everyone is able to see easily and according regulations, including CLP 2008 (Article 31) and Weights & Measures Regs 2006 it should be labelled in a font size that does not result in the “loss of legibility to the consumer.” So retailers, if you ask your customers “can you see the writing on this label/box” and the answer is “No!” then check with your local Trading Standards and your supplier. This could be an issue.
 

3 Interpretation = Confused.com
It’s been hard for manufacturers and retailers to get their heads around what the TRPR actually means. TSOs are probably going to have the same issue. As there is no guidance for enforcers, it is very likely that they will use the “Labelling”/”Product Presentation” requirements from Sections 37 and 38 of the TRPR as a checklist along with their interpretation.

I sense that term “harmonised enforcement” is a very comical thought. To put it bluntly, each local council TSO can have a different understanding of any line of the TRPR and hence enforce it differently. Here is an example of what I mean:

“(2) The unit packet and any container pack of the electronic cigarette or refill container may not include any element or feature falling within paragraph (3).

(3) An element or feature falls within this paragraph if it—
(d) resembles a food or a cosmetic product; or…”

This line has already seen some enforcement in some areas of the UK, resulting in some products being seized. You might remember this photo being passed around social media last month:

TradingStandards Edited

Now this is where manufacturers have become confused. Does this mean that a bottle or box can’t look like something you’d find in a supermarket cereal aisle or like a bottle of your favourite perfume? More than likely! OR Does it mean that you can’t have a graphic of an apple to show that your e-liquid is apple flavoured? Who knows!

Actually this line crosses over with an existing piece of legislation known as The Food Imitations (Safety) Regulations 1989. This basically says that no product should look like (amongst other things) foodstuffs because it would be “likely to cause persons, in particular, children to confuse them with food.” So based on that line, having an apple, a marshmallow, a donut on your product packaging should not result in that product being seized by TSO’s. Yet the photo above suggests otherwise...

This a perfect example of where interpretation between different local TS can cause massive issues. Take my employer who supplies across the country: Swansea TS could give our packaging a thumbs up but a TSO in York, or anywhere else for that matter, could give the products a thumbs down. So how can this situation be avoided?

4 Let your Local Trading Standards handle it
Provided that you’ve followed the guidance from your own local TSOs on packaging, (mainly because the MHRA guidance is a smidge contradictory with the TRPR itself) continue to work with them. There is an agreement between a manufacturer or retailer and the local Trading Standards department under what is known as “Primary Authority”. This has a statutory basis and if your own trading standards gives a thumbs up but another doesn’t then the discussion on the possible non-compliance is held between the two different local Trading Standards departments. Another bonus is that, depending on the Trading Standards, you might have a dedicated TSO that will deal with your company. This is not a free service but I am sure that it will offer some solace amongst all the other stresses.

I hope for the sake of vapers in the UK that manufacturers AND retailers strike up a conversation with TSO’s and continue to talk to each other. I am sure that all vapers would love to see their favourite brands and flavours in shops. I am also sure that vaping businesses want to see their brands flourish as much as possible in what has now become some sort of level playing field. The only way that EVERYONE can be made happy is to work together to get through this.

Finally, remember that Trading Standards Officers are not just “spoil sports” or “clouds of doom” who remove non-compliant or dangerous items from sale but they can also be your “right hand man” or “right hand woman” for advice.

 

 

NNA Sweden logoNew Nicotine Alliance Sweden (NNA Sweden) is a brand new Swedish Tobacco Harm Reduction promoting civil society, started early in 2017. NNA Sweden is an affiliate of NNA UK and NNA AU, as well as a member organisation of the global network of consumer advocacy organisations for safer nicotine products, INNCO.org.

The public launch of NNA Sweden took place at the Swedish premiere of A Billion Lives on February 7th. The premiere sported Aaron Biebert, snus advocacy crowds, vaping advocacy crowds, politicians, health economists and decision makers from the Swedish tobacco control landscape. The initial board of trustees for NNA Sweden are Atakan Erik Befrits from policy research, Ms Jennie Gejel a veteran vaping expert and Mr Patrick Pihl who is a 25 year veteran of snus advocacy and covers snus science in Sweden.

NNA Sweden aims to give a valuable contribution to both Swedish tobacco control policy work and to the important international work being done to safeguard rights to harm reduction products and policy.

Please feel free to contact us at any time to discuss cooperative efforts, access to Swedish data and experience or just to say hello.

Kind regards
Jennie, Patrick and Atakan

 

One of the outstanding weaknesses in some recent research into e-cigarette use is the obvious lack of knowledge that some researchers and commentators have about the workings of vaping devices. indeed, whether by accident or design, some massive 'bloopers' have been made and those have had serious repercussions. How many smokers have disregarded alternative advice and have continued to smoke?

It is difficult for people who are in the front line: people who vape, to express their thoughts and counter the 'wittering's' of some experts. It is difficult for shopkeepers, hairdressers and used car salesmen to have their voices heard above the 'babble' of health professionals, politicians and media presenters all proclaiming loudly, this, that and the other.

Yet... Who are the experts when it comes to vaping? More importantly, are they really experts? Let us take a quick tour and have a look at what some 'experts' have said about vaping.

Let me start with what is to my mind, one of the 'daftest' ones. E-cigarettes may cause tuberculosis. That is correct, e-cigarettes may cause tuberculosis.
The following comment appeared in the Cape Bretton Post of 2nd January 2014. It was written by an 'expert.' (But not a medical expert)

“Now most of the e-cigarettes sold here are made in China, where there is very weak government regulation with respect to how they are made. The Canadian government does not know if Chinese workers making cigarettes wear masks. If they aren’t wearing masks, there are increased risks associated with tuberculosis.”

Scary stuff...

I spotted this at the time and wrote to the professor, pointing out that...

"This is just about one of the most ridiculous statements have ever come across. Pure, unsubstantiated scaremongering and an indication of the lack of care you have taken with your research.

There is a beautiful irony here. Some ‘idiot’ has reasoned that if there is tuberculosis in China, there must be a risk involved. You have decided to parrot this. And here is the irony! You see, the main ingredient in e juice is propylene glycol. Propylene glycol is a disinfectant. And, do you know what? It is used extensively in the war against… yes… come on now… Think! That’s it… Tuberculosis!"

Yes, I know, just because propylene glycol is a constituent in e-liquid does not mean it would prevent infection via vaping - but there again, there are, as far as I am aware, no cases of tuberculosis having been caused through vaping.

Anyway, I am not an expert. Oh! And you may have noticed that my propensity for using emotive terminology has not changed between my writing back then and now - I offer no apology even though scientists avoid doing this... or do they?

How about...

A million times more harmful that outdoor air[source]

An emotive headline but did the researcher claim this? It would appear he did. “[Level of PAHs] in e-cigarettes is at least one million times more than roadside air in Hong Kong,” said Dr Chung Shan-shan, assistant professor in the university’s biology department." The study itself turned out to be 'pure garbage,' sorry, I must stop doing that. The study itself contained one or two weaknesses. No, back to my own style: It was not worth the paper it was written on, or perhaps I should say, the papers it was written in, because I am not sure if the research was ever published except in the world press.

2
It is not a one off... The New England Journal of Medicine [Published by Marvel Comics? I can say this because I am not an expert and have no ambition to have anything published in publications of disrepute] The New England Journal of Medicine published a report that started a media frenzy.

However, is was soon revealed that, once again there were major flaws.

Clive Bates said the following in his article, Spreading fear and confusion with misleading formaldehyde studies.

"This experiment, published in the New England Journal of Medicine, operated the vaping device at a such a high temperature that it produced thermal breakdown products (so-called dry puff conditions), but no user would ever be able to use it this way – the vapour would be too acrid. They went on to calculate human cancer risk from these unrealistic machine measurements and presented the data in way that was bound to mislead, which it duly did and created a world-wide media storm. This was irresponsible science, careless publishing, and credulous journalism adversely changing the perceptions of the relative risks of smoking and vaping in a way that will cause harm. The paper should be retracted in its entirety".

And on and on and on. 'Experts,' media, spouting crap, anything to demonise this perceived threat - and not necessarily a threat to the vaping consumer. Lipoid 3Pneumonia, Tuberculosis, cancer, gateway,However, thank goodness, there are real experts out there. [Note, no inverted commas].

And now we come to the present day, yesterday in fact. Yesterday I read an article by Sofia Carlsson, Associate Professor, Institute of Environmental Medicine, Karolinska Institute, and Cecilia Magnusson, Professor, Department of Public Health Sciences, Karolinska Institute, here. [You may have to use translate] 

They discuss a paper purporting to show a connection between heavy snus use and diabetes type 2. Before saying anything about this, in the above [linked] article they stress, and stress it more than once, that we should not jump to conclusions as there may be confounding factors - how very refreshing...

4They also state as a fact: "Smoking is an established risk factor for diabetes, and a new problem in previous studies has been to separate snuff effects from smoking as inter use is common."

This comment started warning bells ringing. So  I Googled (five minutes' worth) and the very first thing I came up with was... (page 250)

"Then there are quirky findings. In the Sweden study, researchers also looked at the risks associated with using "snus."... In this study, and in contrast to smoking cigarettes, the use of this nicotine containing product did not significantly increase the risk of diabetes."

Oh aye! But it is the next paragraph I find really interesting.

"The Hopkins' study also had an unexpected finding. Although cigarette smoking was clearly linked to type 2 diabetes, stopping smoking led to higher short term risk. highest in the first three years after cessation with a hazard ratio of 1.9.
The last finding is a head scratcher. A report from the University of Oxford, England, involved 1,919 patients followed over 6 years. Of these subjects, 1,216 were initially free of retinopathy

Hang on a second, what on earth is retinopathy? I am not an expert you see. Right, Google: 'Diabetic retinopathy is a complication of diabetes, caused by high blood sugar levels damaging the back of the eye'

and 22% developed the pathology over the next 6 years. Of the 703 persons with retinopathy at the onset of the study, 29% progressed with 2 scale steps or more... Not smoking had an unfavourable effect on the development or progression of retinopathy.

A head scratcher right enough.

Sofia Carlsson, and Cecilia Magnusson, rightly emphasise that there may be many confounding factors but also state that, they, "have also, insofar as possible, taken into account other risk factors for type 2 diabetes such as overweight, physical inactivity, heredity, alcohol consumption, and education level." Did they? I do not have access to the research and even if I did, I doubt that I would understand much of it. It just seems to me to be an echo of previous, dubious e-cigarette studies. It just seems to me that not enough attention has been paid to the lifestyles of the participants... For example, is it the case that, like so many heavy smokers, heavy snus users are concentrated within specific society groupings, that they tend to be less active: that their diets are poorer; they belong to a particular ethnic group. (Some racial, ethnic groups continue smoking cigarettes at higher rates) Whatever...

It seems dubious to me that just because diabetes is higher in heavy snus users that it is the snus which is the cause? The researchers welcome any discussion - so do I.

And please take into account http://www.accessdata.fda.gov/Static/widgets/tobacco/MRTP/18%20appendix-6a-environ-snus-monograph-2013.pdf
Pay particular attention to the sections dealing with diabetes.... and you say that there has been little research. Hmmm!

But why do so many researchers publish materials that that are so far from the truth? What can it be that motivates them to go down this road? Michael Siegel, Professor in the Department of Community Health Sciences at Boston University School of Public Health gives us an insight into the world of Tobacco Control. He paints a picture of a world where individuals are indoctrinated and controlled. A world which will broke no contradiction; suffer any criticism.

He says, in an article, containing a great deal more...

"...if I conduct a study and it fails to show a significant relationship between second hand smoke and chronic disease, then all of the sudden, I have automatically become an illegitimate scientist."

"If it fails to show." Is this why so many 'studies' risk ridicule; a combination of induced blindness and fear?

He concludes...

"I was able to overcome my "brainwashing," but it took a lot of courage to do so, and a lot of risk to my career. I paid a heavy price for breaking out of the mould into which I had been cast. It shattered my career in tobacco control. But at least it didn't shatter me, and the person who I really am."

How many experts show this kind of courage, and the answer, surprisingly, is quite a few... these are the experts, the genuine ones, and their number is growing.

The edifice which is Tobacco Control is crumbling. Soon it will be gone.

Thank God!

 

New Nicotine Alliance would like to offer our thanks to Robert Innes for this guest blog entry. He can be reached on Twitter at @brainyfurball

 

URGENT UPDATE

The EU consultation on excise duties applied to manufactured tobacco  ends on 16th February and includes proposals to tax reduced risk nicotine products. It’s vital that nicotine consumers respond to make their feelings known. If the EU permits taxation on reduced risk products the prices will go up and many people will be discouraged from switching. It’s simple and quick to respond to the consultation - it only takes around 15 minutes. Vapers in Power has done a useful guide to it, here. The Clive Bates/NNA briefing is here.  

RESPOND TO THE CONSULTATION HERE

Let us know how you get on by tweeting to @NNAlliance or by us emailing at This email address is being protected from spambots. You need JavaScript enabled to view it.
If you have already responded then please make it your goal to get three other people to respond too.

Here's a repost of NNA's "EU Tax policy - harmful to health - our briefing", in case you missed it the first time round:

The EU Commission is currently consulting on a revision to the Tobacco Excise Directive, which could see reduced risk products such as e-cigarettes being included. Our associate Clive Bates has written an in depth briefing together with NNA which details why this is a very bad idea. The full briefing can be read here. The consultation can be found here.

There is no case on principled or practical grounds to apply excise duties to vaping products and other products that offer a much safer alternative to smoking.  The value to health and wellbeing associated with switching from smoking to vaping will exceed any benefits arising from revenue collection.

Just as it was with the Tobacco Products Directive, the inclusion of products which do not contain tobacco in the Tobacco Excise Directive is unhelpful and risks creating confusion in the minds of consumers.

If vapour and other reduced risk products are to be included in the directive then our view is as follows:

  • Excise policies on reduced risk products can have a significant negative impact for human health and is inconsistent with EU requirements to make policy with a high level of health protection.
  • The EU principle of 'non-discrimination' requires that products with very different characteristics are not treated in the same way - the vast difference in health risks means that reduced risk products must have zero or very low taxation relative to smoked tobacco products.
  • There is an opportunity to create a regime which will incentivise use of the safer products.
  • The risk is that poor policy will reduce this incentive, and so protect the market for smoked tobacco products.
  • Excise duty is a 'sin tax' and switching to low risk products is a virtue to be encouraged, not a sin to be taxed.

Our recommendations for low risk non combustible products are as follows:

  • If they are included in the directive then a zero rate duty must be allowed.
  • There should be a maximum rate set which reflects the very substantial difference in risk compared to smoked tobacco.

We urge the European Commission, European Council and member state tax authorities to take great care in striking the balance between public health, revenue raising and administrative costs. The institutions involved should conduct thorough impact assessments, take a hard look at the risks of causing harm to health and then think again about imposing excise duties on products that are already helping millions of Europeans to improve their health and wellbeing and have the potential to help millions more.

Please do read the full briefing and have your say. Make sure your MP also understands your concerns.

 

 

 

 


On the day that NNA was in the High Court asking for permission to join the effort to overturn the ludicrous ban on snus, and Hertfordshire County Council were holding their very successful 'e-cigarette masterclass', at which delegates learned about vaping, and sensible vaping policy, Public Health Wales issued their new position on e-cigarettes. http://www.wales.nhs.uk/sitesplus/888/news/43873 

It is difficult to imagine the machinations that must have gone on within PHW whilst coming to this position. Seemingly realising that a failure to admit that e-cigarettes are very much safer than smoking tobacco cigarettes is now akin to being an anti-vaxxer, they grudgingly advise that anyone who is unwilling or unable to stop smoking should switch to vaping instead. Quite why anyone would want to do so given the rest of the PHW statement is anyone's guess.

Cherry picking from the US Surgeon General report, and of course the World Health Organisation, we are told that:

There are no benefits to children or young people using e-cigarettes.

No one wants to see young people initiate nicotine use via any method, but for those who have or will take up smoking there are definite benefits.

'Confectionary-like' (sic) flavours of e-liquid should not be permitted, in order to reduce the appeal of ENDS to children and young people.

How many times do we have to point out that the majority of adults prefer candy and fruit flavours. Certainly these flavours should be marketed responsibly, but in light of the fact that there is no evidence that 'confectionary-like' flavours, or indeed any other flavours, cause young people to take up regular vaping, all that this policy would achieve is to make e-cigarettes less appealing to those adult smokers who, as PHW admits, would benefit from switching.

Until a more definitive risk assessment can be completed, voluntary restrictions on the use of ENDS in enclosed public spaces should continue.

No doubt PHW would have preferred to push for legislative bans, but given what happened last time they tried, they settle for telling Welsh businesses to do that job for them. Contrary to PHW's carefully selected 'evidence' on this issue, there is no evidence at all of a risk of harm to bystanders, or that vaping renormalises smoking.

Additional 'factoids' in the statement include:

"Use of e-cigs may reduce the likelihood of smokers quitting by displacing scientifically proven methods to help people quit."

"The use of ENDS will act as a gateway to tobacco use."

Needless to say there is no evidence to suggest that either of the above concerns are happening in the real world.

In summary, whilst PHW's assertion that for a smoker, switching to e-cigarettes will significantly reduce the risk of harm to health is welcome, this statement is completely outweighed by the very negative comments which follow. We can all guess what this information will look like:

"Public Health Wales will include information on ENDS alongside other aids to stopping smoking in all information materials and in Stop Smoking Wales support services. Information on all products will be presented to support smokers in making an informed choice about the best way to quit for them."


NNA has succeeded in its request to join the challenge against the ban on snus in the UK and the EU.

The High Court agreed on 26th January that the challenge can be referred to the European Court of Justice.  There were two issues before the court.

Swedish Match initiated the challenge to the ban and asked the High Court for a Judicial Review of the legislation. The case was brought against the Secretary of State for Health. The Department of Health opposed the application for Judicial Review on the grounds that it was out of time – they argued that the case should have been brought in 2014 when the Tobacco Products Directive was passed. SM argued that it could not bring a challenge against the law until the EU Directive had been passed into UK law in 2016. The Department of Health did not raise substantial challenges to the details of the Swedish Match case.

NNA’s Gerry Stimson and Jessica Harding were in the court and as the judge spoke it gradually became clear that there would be a positive result. Mrs Justice Lang agreed with SM’s argument that a challenge could only be brought once the law had been passed in the UK. So she agreed that the case could be referred.  She then turned to NNA’s case. We asked to be joined to the case as a third party intervenor acting in the public interest and adding important consumer and health rights arguments. Neither Swedish Match nor Department of Health lawyers objected to our application and the judge agreed that we could be joined to the case.

Because the UK law is based on EU Tobacco Products Directive, the case now has to be referred to the European Court of Justice. So we get a chance to put our view at the ECJ. The UK government has signalled its intention to leave the ECJ post-Brexit, but as of now EU legal processes prevail. The advantage of getting this into the EU legal process is that if the ECJ rules in our favour and against the ban, the ECJ decision applies across the whole of the EU, not just the UK.

It will take about a month for the UK to prepare the case to be sent to the ECJ, and the ECJ will likely take up to 18 months to come to a decision – so there is a long way to go yet!

Even getting this far is a triumph for a new, small consumer advocacy group. NNA was only founded in 2015, is a small group of volunteers and has few financial resources. This shows the potential for consumer advocacy groups to make a noise and make a change. Thanks to everyone who is supporting this NNA campaign to get availability of a wide range of lower risk nicotine products.

Testimony to the Norwegian Parliament on the relative risk of snus from Professor Anders Milton, ex President of the World Medical Association.

More from the NNA on snus:

Leading experts implore the Swedish government to back snus at COP7

Snus facts

NNA goes to the High Court to challenge the ban on snus

Snus ban challenge, NNA media releases from 26th January 2017

 
 
 

Media release at 4.15pm today


The High Court has just announced that it will allow the ban on the smoking substitute snus to be referred to the European Court of Justice.

Professor Gerry Stimson, who is leading the legal challenge to the ban by the consumer group, the New Nicotine Alliance, said:

There’s now a race to see whether European judges or British politicians will lift the ban first. They realise that with British men smoking four times as much as Swedish men we cannot justify continuing the ban on snus. If the European Court doesn’t do it first, I hope that when Brexit happens the bonfire of regulations will begin with this stupid ban on the world’s most successful safer alternative to smoking.

Daily Express 26 January 2017 http://www.express.co.uk/news/world/758965/European-Union-high-court-smoking-snus-Sweden-health 

 

Notes

Snus is pasteurised tobacco product which is placed in a sachet under the lip
The European Union maintains a blanket ban outside Sweden which negotiated an exemption when it joined the EU.
The US Food & Drug Administration authorised snus in November 2015 http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm472026.htm
The New Nicotine Alliance has been intervening in the legal action bought by the manufacturer, Swedish Match
How Snus Got Banned

Snus got banned in Europe because of pressure from the then UK public health minister, Edwina Currie. She was fearful about Skoal Bandits.
The pharmaceutical industry has argued for the ban on snus to continue as it competes with their nicotine gum and patches.
In 2012 the EU Health Commissioner John Dalli was forced to resign following allegations that one of his associates had approached snus maker Swedish Match asking for a bribe: https://en.wikipedia.org/wiki/John_Dalli
EU officials have argued that oral tobacco can be a problem - but in doing this they have confused evidence about chewed South Asian tobacco (e.g. http://www.bbc.co.uk/news/health-19718643 ) with snus which is a pasteurised product created to very tight standards (https://www.swedishmatch.com/Snus-and-health/GOTHIATEK/GOTHIATEK-standard/)

Safety

Is snus much safer than smoking? The answer from key health organisations is emphatically yes.

US Food and Drug Administration: it chose in 2015 to make snus the first nicotine product it authorised because the science is extremely compelling: FDA authorisation
Royal College of Physicians: says that snus “demonstrates proof of the concept” for tobacco harm reduction: “Nicotine Without Smoke” RCP 2016
World Health Organisation: says that snus is “considerably less hazardous than cigarettes”: page 273 WHO Tob. Reg. Report 951
EU Commission: says that “It is undeniable that for an individual substitution of tobacco smoking by the use of moist snuff [snus] would decrease the incidence of tobacco related diseases.”: SCENIHR (2008)
This heavyweight analysis is not just from lab tests, but decades of epidemiology which show that on the key smoking diseases including lung and oral cancer, Sweden is doing far better than other countries.
In a letter to The Times Professors Farsalinos, Le Houezec, Polosa and Ramström wrote that not only did Sweden have by far the lowest rates of lung cancer and heart disease in Europe but that "younger Swedish men, who have the highest use of snus, have the lowest levels of oral, oesophageal and pancreatic cancer.” (18% of Swedish men use snus, but only 4% of women.)
If Sweden’s success was repeated in the UK our male lung cancer mortality would be 54% lower: Scandinavian Journal Of Public Health, 2009 .


Effectiveness

UK ONS data shows around a quarter of men still smoke: see figure 1: 16-24 years 25%; 25-34 years 26%; 35-49 years 22%.

https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2014#smoking-data  (need to c+p into the browser window)
UK Parliamentary answer shows 24% of young men are regular smokers:https://www.parliament.uk/business/publications/written-questions-answers-statements/written-question/Lords/2016-12-06/HL3876/
Swedish data shows far lower male smoking rates:16-29 years 8%, 30-44 years 5% and 45-64 9%. Swedish government data: (daily smoking is under “roker daglinen” tab) https://www.folkhalsomyndigheten.se/documents/statistik-uppfoljning/enkater-undersokningar/nationella-folkhalsoenkaten/2016/Tobaksvanor-nationella-resultat-tidsserier-2016.xls

 

Media release at midnight, before the hearing:

Nicotine campaigners take government to High Court over “disastrous ban”

UK is “failing very badly” at reducing smoking compared with Sweden

A consumer group that aims to ensure smokers have safer alternatives to cigarettes is today challenging the government in the High Court in a bid to lift a European Union ban on the oral tobacco product snus. The New Nicotine Alliance led by Professor Gerry Stimson of Imperial College London wants snus - which is used by a fifth of all men in Sweden - to be legalised.

Sweden has by far the lowest rate of smoking in the developed world. Government figures show that just 5% of its men aged 30 to 44 years old are regular smokers compared with 22% in the UK. Scientists conclude that the widespread use of snus as an alternative to smoking is the reason that diseases including lung and mouth cancer are far lower in Sweden.

“The UK is failing very badly compared with Sweden at bringing down smoking rates. It is a tragedy that we have four times as many men in their thirties smoking than in Sweden and disastrous that we are banning the most successful alternative to the biggest cause of preventable death,” said Professor Stimson.

The professor will be telling the High Court of research which shows that male lung cancer rates in the UK could more than halve if it had similar levels of snus use to Sweden. He is particularly angered that some Swedish and Norwegian users have started smoking when they move to the UK because they can’t get their snus here.

“Everyone was taken by surprise by the way millions of smokers flocked to e-cigarettes to help them quit smoking. Yet nine million people in the UK continue to smoke and proven alternatives like snus should be available to help those who want to quit. Smokers should have the widest choice of reduced risk products so that they can find the one that works for them” said Professor Stimson.

In parallel with today’s legal attempts to overturn the ban, a group of 22 Conservative MPs has written to the Health Secretary urging him to include snus in his forthcoming Tobacco Control Plan which will cover Britain’s smoking policy after Brexit.

 

Notes

Snus is pasteurised tobacco product which is placed in a sachet under the lip. For more information see ‘Snus facts’ at http://nnalliance.org/blog/162-snus-facts
The European Union maintains a blanket ban outside Sweden which negotiated an exemption when it joined the EU.
The US Food & Drug Administration authorised snus in November 2015 http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm472026.htm
The New Nicotine Alliance is seeking to intervene in the legal action which has been bought by the manufacturer, Swedish Match
UK ONS data shows around a quarter of men still smoke: see figure 1: 16-24 years 25%; 25-34 years 26%; 35-49 years 22%. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2014
UK Parliamentary answer shows 24% of young men are current smokers: https://www.parliament.uk/business/publications/written-questions-answers-statements/written-question/Lords/2016-12-06/HL3876/
Swedish data shows far lower male smoking rates:16-29 years 8%, 30-44 years 5% and 45-64 9%. Swedish government data: (daily smoking is under “roker daglinen” tab) https://www. folkhalsomyndigheten.se/ documents/statistik- uppfoljning/enkater- undersokningar/nationella- folkhalsoenkaten/2016/ Tobaksvanor-nationella- resultat-tidsserier-2016.xls (need to c+p into the browser)
18% of all Swedish men use snus daily. Swedish government data: (see “snusar daglinen” tab on spreadsheet) https://www.folkhalsomyndigheten.se/documents/statistik-u
The Royal College of Physicians describes snus as “proof of concept for harm reduction.” See page 31 https://www.rcplondon.ac.uk/projects/outputs/fifty-years-smoking-and-health
“It is undeniable that for an individual substitution of tobacco smoking by the use of moist snuff [snus] would decrease the incidence of tobacco related diseases.” EU Commission, SCENIHR (2008)
World Health Organisation has said it is “considerably less hazardous than cigarettes” WHO Tob. Reg. Report 951, Scientific Basis of Tobacco Product Regulation, 2008
The University of Michigan’s Dean of Public Health stated that “everyone who has studied this agrees there is a 95%–99% reduction in the health risk of snus, compared to use of cigarettes.” Journal of the National Cancer Institute 2010 https://academic.oup.com/jnci/article/102/19/1454/2516186/Snus-Use-in-the-U-S-Reducing-Harm-or-Creating-It?searchresult=1
“Nicotine itself is not especially hazardous, and if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved.” Royal College of Physicians, Harm Reduction in Nicotine Addiction: Helping People Who Can’t Quit (2007)

 

Testimony to the Norwegian Parliament on the relative risk of snus from Professor Anders Milton, ex President of the World Medical Association.

 More from the NNA on snus:

Leading experts implore the Swedish government to back snus at COP7

Snus facts

NNA goes to the High Court to challenge the ban on snus

Update on the challenge to the ban on snus – next step, the European Court of Justice

NNA snus ban challenge - update May 2017

NNA snus ban challenge - the legal case

Snus and the right to health

 

 

 

 

What do we know about snus?

What is snus?

Snus is a moist, smokeless powdered tobacco. It is sold as a loose powder or pre-packaged in a small sachet (a bit like a mini tea bag). It contains ground tobacco, salt and may contain food-grade smoke aroma flavourings, such as citrus, bergamot, juniper, herb or floral flavours. Most Scandinavian snus is produced in Sweden where it is regulated as a food under the Swedish Food Act. The nicotine content varies among brands.

Is snus an appropriate and acceptable harm reduction product?

Snus fulfils the criteria for a tobacco harm reduction product. It is a low risk nicotine product and delivers acceptable doses to those who use it. In countries in which it is allowed it is popular and has contributed to declines in smoking and smoking related diseases.

How does snus differ from other oral tobaccos?

Snus is a smokeless tobacco. Unlike some other smokeless tobacco types, Swedish snus is not fermented and is pasteurised, which inhibits the growth of bacteria that help the formation of tobacco-specific nitrosamines (an important group of carcinogens in tobacco products). Snus is refrigerated in order to inhibit the growth of toxins.

How is snus used?

Snus is placed between the upper lip and gum. The nicotine is released into the saliva, with the rate of release affected by the amount of saliva. New users experiment (titrate) to find the best rate of nicotine release. http://www.wikihow.com/Use-Snus

Is there a quality standard for snus?

The Gothiatek standard, a voluntary quality standard for snus products, has maximum levels for constituents, including nitrosamines, metals, nitrite, agrochemicals, mycotoxins and aldehydes.
https://www.swedishmatch.com/Snus-and-health/GOTHIATEK/GOTHIATEK-standard/

Is snus safe and are there any long-term health effects?

Snus is considered by scientists to be 95%, and possibly closer to 99%, less risky than smoking.

Snus poses no respiratory risk. Respiratory diseases, predominantly lung cancer, chronic obstructive pulmonary disease (COPD) and pneumonia account for 46% of deaths due to smoking, according to the Scientific Committee on Emerging and Newly Identified Health Risks, 2008.
http://ec.europa.eu/health/ph_risk/committees/04_scenihr/docs/scenihr_o_013.pdf

Individual studies can produce contradictory findings so evidence must be sought from overviews of key studies and pooled results. A recent systematic review and meta-analysis examined the evidence relating to snus and health across six major Swedish, Norwegian, Danish and Finnish studies, up to 2010. This concludes that the evidence provides scant support for any major adverse health effects of snus: snus is not associated with cancers of the oropharynx, oesophagus, pancreas, or heart disease or strokes. Compared with smoking snus poses about 1% of the risk of cancer or cardiovascular disease. https://www.ncbi.nlm.nih.gov/pubmed/21163315

Snus and lung cancer in Sweden

The rise in the use of snus has resulted in Sweden having the lowest lung cancer mortality and tobacco-related mortality in Europe. It is estimated that if the Swedish smoking prevalence was extrapolated to the rest of the EU, there would be a 54% reduction of male mortality from lung cancer. (Rodu B. and Cole, P. 2009. “Lung Cancer Mortality: Comparing Sweden with Other Countries in the European Union.” Scandinavian journal of public health 37(5):481–86.)
http://journals.sagepub.com/doi/abs/10.1177/1403494809105797

Health effects of switching to snus

Given the lower risk profile for snus it has been calculated that the life expectancy of smokers who switch from smoking to snus is little different to the life expectancy of those who stop smoking altogether. The authors of this study conclude that: ’Individual smokers who switched to snus instead of continuing to smoke and new tobacco users who only used snus rather than smoking would achieve large health gains compared with smokers’.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60677-1/abstract

This finding is confirmed by a recent analysis of six major studies which found that switching from smoking to snus is associated with major reductions in morbidity and that switching to snus appears to have much the same reduced health risk as quitting smoking.
http://europepmc.org/abstract/MED/23454227

Does snus pose a risk to others?

Snus poses no risk to others, such as work colleagues and family members as there is no combustion and consequently no ‘second hand’ smoke and no risk of fire.

Snus and stopping smoking

Snus is now the most popular product for smokers in Sweden and Norway when they wish to stop smoking and the success rate is higher when using snus than when using pharmaceutical Nicotine Replacement Therapy products.
https://academic.oup.com/ntr/article/14/10/1221/1749452/Association-Between-Willingness-to-Use-Snus-to

Has snus replaced smoking in Sweden and Norway?

Consumers in both Sweden and Norway are choosing to use snus rather than to smoke. There has been a major increase in the use of snus and a concomitant decline in the smoking of tobacco. In Sweden, snus overtook cigarettes in 1996; In Norway the rise of snus and the decline in smoking resulted in male use of snus overtaking cigarettes by 2006. This happened despite snus use in Sweden and Norway occurring in a context where active promotion of the product was banned and health authorities warned smokers against snus use.

What are the levels of smoking in Sweden?

The prevalence of current adult smoking in Sweden in 2014 was 11% and Sweden now has the lowest prevalence of smoking in the EU. In the same survey in 2014 the prevalence of adult current smoking in the UK was 22% (European Commission. Attitudes of Europeans towards Tobacco and Electronic Cigarettes. European Commission; Brussels, Belgium: 2015. Special Eurobarometer 429).

‘Daily smoking’ is even lower in Sweden at 8% compared with 19% in the UK in 2014.

Smoking is fast disappearing in some groups of Swedish men: in 2016 in the 30 to 44 years age group only 5% are daily smokers, less than a quarter of the level in the UK men. https://www. folkhalsomyndigheten.se/ documents/statistik- uppfoljning/enkater- undersokningar/nationella- folkhalsoenkaten/2016/ Tobaksvanor-nationella- resultat-tidsserier-2016.xls

How does the use of snus reduce smoking?

Snus is used to avoid the uptake of smoking, to stop smoking, and to reduce smoking.

The decline in Sweden and Norway has come about by smokers using snus to avoid smoking, and by the fact that younger nicotine users are choosing to use snus rather than to smoke, and that the uptake of snus does not lead to tobacco smoking.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4245639/  and https://www.ncbi.nlm.nih.gov/pubmed/27834883 )

Overall in Sweden and Norway the total level of tobacco use has remained stable or slightly declined – what is important is that there has been a major shift away from smoking.

Snus can therefore be considered protective against smoking.

Might other factors in Sweden account for the switch to snus?

No. Sweden has implemented fewer tobacco control measures than the UK. Laws on tobacco use and promotion are less strict that in the UK. They don't have a fully 'comprehensive' smoking ban. Smoking is allowed in designated purpose built smoking rooms in some workplaces and some public places like airport terminals. Smoking is also permitted in designated smoking areas outside in train stations and bus terminals. They don’t have especially high tobacco taxes. There is a ban on tobacco advertising and promotion, but advertising and promotion is allowed at points of sale, as are tobacco product displays. There are total restrictions on tobacco sponsorships.

The clear difference between Sweden and the UK is due to snus. Overall the UK ranks number 1 in implementing tobacco control measures, whilst Sweden ranks joint 9th in 2016. http://www.tobaccocontrollaws.org/legislation/country/sweden/summary Sweden gets better results with fewer controls on smoking.

What does the Royal College of Physicians, Tobacco Advisory Group say about snus?

‘The availability and use of an oral tobacco product known as snus in Sweden, documented in more detail in our 2007 report…demonstrates proof of the concept that a substantial proportion of smokers will, given the availability of a socially acceptable and affordable consumer alternative offering a lower hazard to health, switch from smoked tobacco to the alternative product. Particularly among men, the availability of snus as a substitute for smoking has helped to reduce the prevalence of smoking in Sweden, which is now by far the lowest in Europe…Trends in snus use in Norway are similar to, and perhaps stronger than, those in Sweden, and there the use of snus is strongly associated with quitting smoking.’ Royal College of Physicians, Tobacco Advisory Group (2016). Nicotine without smoke: Tobacco harm reduction

Legal status of snus

Snus is banned from sale in the EU (except in Sweden).

The UK Tobacco and Related Products Regulations 2016 and EU Tobacco Products Directive 2014 on which it is based states that ‘no person may produce or supply tobacco for oral use’. Tobacco for oral use is defined as:

A tobacco product which is –
(a) intended for oral use, unless it is intended to be inhaled or chewed; and
(b) in powder or particulate form or any combination of these forms, whether presented in a sachet portion or a porous sachet, or in any other way’.

How did snus come to be banned?

In 1989 the UK Oral Snuff (Safety) Regulations were passed in response to the introduction of the moist snuff marketed as ‘Skoal Bandits’. This ban was quashed on appeal by the manufacturer.

In the EU, Directive 92/41 banned sales of snus, to harmonise rules in that three member states had already banned tobacco for oral use.

In 1995, on accession to the EU, Sweden obtained an exemption from the ban.

In 2001 the Tobacco Products Directive continued the ban.

The ban was also continued in the 2014 Tobacco Products Directive.

The legal challenge

The Swedish Match legal challenge against the ban on snus

Swedish Match – the main manufacturer of Swedish snus – has brought a challenge in the UK High Court against the ban of the sale of snus. Their legal argument is that the law discriminates against snus compared with cigarettes and with lower risk nicotine products, that the ban is disproportionate, is against the principle of subsidiarity in removing national regulatory discretion, breaches the duty to give reasons for the ban, and is an unjustified restriction on the free movement of goods.

The NNA legal challenge against the ban on snus

NNA asked the High Court to be joined to the case as an ‘intervenor’. NNA is acting as a third party in the public interest, and brings added facts and argument to the case.

NNA argues that the ban is (a) disproportionate, and (b) contravenes the right to a high level of health protection.

Significantly, for the first time in a challenge against UK (and EU) tobacco legislation, NNA argues that the ban infringes human rights. NNA argues that the ban contravenes the EU Charter of the Fundamental Rights vis Art 1 ‘human dignity’, Art 7 ‘respect for private and family life’, and Art 35 ‘health care’.

Art 35 stipulates that a high level of human health protection shall be ensured in the EU policies and activities. NNA argues that the ban is inappropriate as it prevents smokers from having access to a safer product and is an unsuitable means for achieving a high level of health protection.

Progress with the case

The High Court agreed on Jan 26th 2017 that there was a case for a review of the legislation. Because the UK Tobacco and Related Products Regulations 2016 are based on the EU Tobacco Products Directive 2014, the case was referred to the European Court of Justice, on 9 March 2017.

Implications of the case

The ECJ ruling will apply across the EU.

Why did NNA get involved in this case?

NNA sees access to all safer nicotine products as important in helping provide smokers with lower risk alternatives to smoking – so lo-tech snus is important as well as hi-tech e-cigarettes. NNA contends that snus fulfils the criteria for a tobacco harm reduction product and that it should be available in the UK.

 

pdfDownload this as a PDF here 

 

Testimony to the Norwegian Parliament on the relative risk of snus from Professor Anders Milton, ex President of the World Medical Association.

 

More from the NNA on snus:

Leading experts implore the Swedish government to back snus at COP7

NNA goes to the High Court to challenge the ban on snus

Snus ban challenge, NNA media releases, 26th January 2017

Update on the challenge to the ban on snus – next step, the European Court of Justice

NNA snus ban challenge - update May 2017

NNA snus ban challenge - the legal case

Snus and the right to health

An image of Snus

NNA is seeking to overturn the UK and EU ban on snus. Snus is a popular and effective harm reduction product which has helped thousands in Sweden and Norway to avoid the risks of smoking. As a result Sweden and Norway have the lowest rates of lung cancer in Europe. But the sale of snus is banned in the EU, except in Sweden. The TPD was bad for e-cigarettes, but worse for snus. We will tell the court that the ban is harmful to health and that UK smokers deserve a better deal – the snus ban kills.

E-cigarettes are having a major impact, but they don’t work for everyone in all circumstances. We want to see wide availability of all safer nicotine products as alternatives to smoking.

Everyone was taken by surprise by the way millions of smokers flocked to e-cigarettes to help them cut down or stop smoking. Yet nine million people in the UK continue to smoke and proven alternatives like snus should be available to help those who want to switch away from cigarettes. When smokers have the widest possible choice of reduced risk products it increases the likelihood of their finding an option that works for them.

Snus is a popular and effective harm reduction product. But the sale of snus is banned in the EU, except in Sweden. The TPD was bad for e-cigarettes, but worse for snus. The EU continued with the ban despite huge evidence for the safety and impact of snus, and despite the overwhelming view of consumers who told the EC that the snus ban should be lifted.

NNA contends that snus fulfils the criteria for a tobacco harm reduction product and that it should be available in the UK.

That is why we are going to the High Court on Thursday 26th to ask for the ban to be lifted. We are piggy-backing on Swedish Match’s request for a Judicial Review of the ban on snus. NNA is asking the Court to be allowed to make its own submission in order to provide a consumer perspective on the ban and of the benefits that will follow if the ban is lifted.

If the High Court agrees that there is a case to answer the case will be forwarded to the European Court of Justice. This is because the UK law is based in EU law - and yes – we are still in the EU as of now and the ECJ process still stands. If, and it’s a big IF, the case is referred to the ECJ, and IF the ECJ rules against the ban then this decision would apply across all of the EU. So, there is a lot at stake.

Snus is much safer than smoking tobacco. Some 46% of deaths due to smoking are respiratory diseases, predominantly lung cancer, chronic obstructive pulmonary disease and pneumonia. Without the inhalation of smoke then for these diseases alone half of premature deaths can be avoided.

Sweden now has the lowest lung cancer and tobacco-related mortality in Europe. There is scant evidence for any major adverse health effects of snus: snus is not associated with cancers of the oropharynx, oesophagus, pancreas, or heart disease or strokes. Switching to snus appears to have much the same reduced health risk as stopping smoking. Snus is not completely free from adverse health effects but these are miniscule compared with the risks of smoking. Snus poses no risk to others as there is no ‘second hand' smoke.

Snus protects against smoking by reducing the uptake of smoking, helping people reduce smoking, and helping people to stop. In Sweden and Norway the increase in the use of snus has been accompanied by a major decrease in smoking. As a consequence the prevalence of male adult smoking in Sweden and Norway is now the lowest in Europe at 11% and 13% respectively.

Smoking is fast disappearing amongst some Swedish men: in the 30-44 year age group only 5% are daily smokers, less than a quarter of the level in the UK.

NNA will tell the court that the ban on the sale of snus is incompatible with evidence for its safety in comparison with smoked tobacco cigarettes and that the ban is against the interests of individual and public health.

The application is supported by Witness Statements from myself, Karl Lund – the leading Norwegian expert on snus, Louise Ross – NNA Associate and an expert on stop smoking services and alternative products, and Judy Gibson - from the International Network of Nicotine Consumer Organisations.

Watch the NNA website and follow @NNAlliance on Twitter and NNAlliance on Facebook for updates on the case and please share our posts on social media.

NNA’s view reflects the weight of consumer opinion in the EU that is overwhelmingly in favour of lifting the ban on snus: according to evidence from the European Commission itself some 83% of the 70,925 who responded to the consultation on the Tobacco Products Directive wanted the ban removed.

We will tell the court that the ban is harmful to health rather than protective of health; that it discriminates against products and consumers, and works against the achievement of a high level of health protection. UK smokers deserve a better deal – the snus ban kills.

Gerry Stimson
Chair NNA on behalf of the Trustees

         

Testimony to the Norwegian Parliament on the relative risk of snus from Professor Anders Milton, ex President of the World Medical Association.

 

More from the NNA on snus:

Leading experts implore the Swedish government to back snus at COP7

Snus facts

Snus ban challenge, NNA media releases, 26th January 2017

Update on the challenge to the ban on snus – next step, the European Court of Justice

NNA snus ban challenge - update May 2017 

NNA snus ban challenge - the legal case 

Snus and the right to health

 

NNA associates attended a debate at London South Bank University on Tuesday evening entitled “A way forward – How e-cigarettes could and should affect public health” which, sadly, only resulted in conveying an entirely misleading message to the approximately 50 people in the auditorium along with many more who logged on to watch a live stream of the event on Facebook.

Unfortunately, most of the panel did public health a significant disservice by repeating almost all the ill-informed canards that their more enlightened colleagues have sought to dispel over the past few years about vaping.

A photo from the LSBU debate.

For example, Faculty of Public Health board member Patrick Saunders began the evening stating confidently that there is evidence that e-cigarettes inhibit smoking cessation rather than help smokers switch to vaping – which is quite wrong - and followed up later by dramatically declaring e-cigarettes to be “designed to mimic smoking, are intended to mimic smoking” with no recognition that this might be a positive attraction for smokers wishing to quit. He also said that it was “encouraging to see most places ban smoking and vaping” without a care that Public Health England has rightly identified the public health advantages of vaping being permitted where smoking isn’t.

Professor Andy Parrott of Swansea University – when not advocating for public information films showing tumours and gore to be shown on CBeebies – added that “nicotine is the ideal training drug for addiction” leading to addiction to harder drugs; an idea entirely unsupported by any science, and said that he would recommend nicotine patches over e-cigarettes despite research proving the latter to be more effective.

Dr Helen Walters of the National Institute of Health Research, while mildly supportive of vaping, also appeared to be singing from the vape-sceptic hymn sheet by declaring that she was happy that evidence shows e-cigarettes not to be a gateway into smoking for children in the UK, but that it is a different situation in the US despite youth smoking rates plummeting across the Atlantic too.

It was quite clear that some panellists possessed scant knowledge of the research conducted on e-cigarette health effects and usage, while in amongst all this was Professor Peter Hajek attempting to share the real evidence but being largely ignored in favour of falsehoods spread by other ‘experts’ on the panel.
If that was disappointing, it only deteriorated further once discussion was opened to the floor. One by one all the lazy myths about vaping came tumbling out, and there was precious little pushback from the panel to correct them.

The oft-repeated misconception was advanced that a former smoker used his vaping equipment far more often – thereby implying he was self-administering more harm - without anyone pointing out that e-cigarette nicotine delivery is more dilute and tempered compared with smoking so this is a normal occurrence. Public health officers were forthright in condemning e-cigarettes for “substituting one addiction for another” without being educated that nicotine is on a par with caffeine, while another public health professional asserted boldly that “nicotine doesn’t break any kind of habit”, which any e-cigarette user will be able to tell you is not the case.

As for the idea that people might actually enjoy using nicotine and that the safer it is delivered, the better, the wholly clinical approach to the subject matter meant that the very premise was not up for discussion. Although it is encouraging that a London university decided to schedule an event on vaping, it was not so much a debate as a kangaroo court whereby vapers were offered no real defence.

If these misconceptions are to be addressed, and assuming the public health community truly wants to properly understand the attraction of vaping and its potential for public health, it is essential that this kind of event includes people who can do exactly that. Not, as was the case on Tuesday, in the audience with the chance of a minute or two at most to counter the untruths, but on the panel with a microphone given equal prominence and respect. The NNA can boast dozens of citizen experts who are qualified by their experience to talk about the subject and who are far more knowledgeable than many of those on display at South Bank University.

If those entrusted with advising parliamentarians and policy-makers wish to make a positive contribution to public health in the UK, they simply cannot preach ignorantly from their privileged pulpit like this. On Tuesday, they sent a cohort of local authority public health officers and interested students out into the chilly London air with negative, incorrect and evidence-free opinions about vaping to share with their friends and colleagues. They had been informed by ‘experts’, after all.

The way this event was structured may have been well-meaning, but in practice it has caused harm by effectively disparaging a technology which carries huge beneficial potential for population health in the UK and beyond. Health debates like this must include consumer advocates to offer a differing – and informed – view in the future; to not do so is nothing short of ideological public health vandalism.

 

Andrew Hall may not be the most competent vaper on the planet, but he’s not solely to blame.

You may have seen the media stories today about the Idaho man whose e-cigarette exploded. It seems he was using a hybrid mod. The vast majority of e-cig users use regulated mods containing inbuilt electronic safety features which mechanical and hybrid mods do not have. No reputable vendor will sell a hybrid or mechanical mod to a non advanced user.

NNA trustee David Dorn explains more below:

If you are not aware that Facebook managed to bring the notion of battery and mech mod safety to the fore on January 16th 2017, then you’ve missed a watershed moment in vaping circles.

Let’s precis:
Before the Deeming rules came into force in the USA, Andrew, apparently, was using a mechanical mod (that is to say a battery unit with no electronics to protect or regulate the power of the device). It seems to have been a hybrid mod. A hybrid has no 510 connector as we all know it, but simply has a thread to attach a dripper or tank, and relies on the centre post of the dripper (we’ll say) contacting the positive terminal of the battery cell when it’s pushed up by the bottom button.
Such a device is inherently unsafe unless a number of criteria are met:
1: The tank or dripper - the atomising device - MUST have a protruding centre contact.
2: The contact cannot be sprung or articulated in any way that would allow the battery’s positive terminal to make contact with the threaded section
3: No matter how far the atomising device is screwed into the hybrid connector, it must never make contact with the positive terminal of the battery unless the button has been pressed
4: Each and every battery used in the device can have no splits, tears or cracks
And that’s just the tube itself. If any one of those criteria are not met, there is a very much increased chance of a short circuit scenario occurring, and when a battery cell is short circuited, then thermal runaway is highly likely.
As I said, that’s just the battery tube.


Resistance is not futile
The next weak link is the coil itself. Generally speaking, in a regulated device, the resistance of the coil(s) is matterless. As long as said resistance falls into the range that the mod can handle, it will deliver regulated power at the user’s chosen level without any issues. If the resistance of the atomiser setup is too low, the electrnics therein will prevent any current from flowing.
Not so with a mech or hybrid. There is no intelligence.
Reports suggest that Andrew was using a 0.06ohm coil - and although this is far from confirmed, such resistances in coils are not unusual. And that would be fine if, and only if, the battery cell in the device was capable of handling the currents generated when the setup is powered up. In this case, Andrew was expecting an 18650 battery to produce something over 50 Amps (bordering on 200 watts).
Without wishing to alarm too many people (just the right ones) there is no 18650 on the market which will produce that much power safely and reliably. Many will do exactly what his did and vent/blow up.
In the scenario where a hybrid mod is used and the connector on the atomising device is either flush or recessed, a dead short will occur. In this case, the resistance of the coil is matterless - there is no resistance to the current, and thermal runaway can be almost instant, with little or no notice. It looks awfully likely that that is what happened in this case.


Avoidable?
Yes - this kind of thing is totally avoidable. The generality of users, as with all generally available stuff, ought not to need to know Ohm’s law in order to use an ecig safely. That it is not only possible, but also very easy to buy a battery unit which is fully protected, can produce high power and massive clouds, and will not allow you to put yourself in danger by mismatching bits of the setup. Not only that, but such mods will very often be considerably cheaper than boutique hybrids and mechs - it’s not difficult to choose a battery unit that will produce exactly what you need in terms of safely generated power - there are many on the market.


So where next?
This is the controversial bit. Look, there are folks out there who are unwittingly lead into purchasing hybrids and mechs. They are, frankly, sexy, “scene”, used by the top echelon of trick vapers and there is a level of kudos applied to users of the most sought-after units. I get that.
But they should NOT be the default “next step” in a vaper’s journey. Indeed, were it up to me, I’d be asking vendors not to display them or advertise them. The vast bulk of mainstream vapers are not competent to use them safely. (That’s not to say that those vapers are in any way second class or deficient. For instance, I am not competent to service a motorcycle - it’s not because I’m thick, it’s because I don’t have either the necessary skills or training to do so safely - and when it comes to hybrids, particularly, mistakes are all too easy to make).
So, my plea to vape shops”
1: don’t display hybrids and mechs - those vapers who understand them and know them will know you have them. Let them ask.
2: should someone wander into your shop with an ego or an iStick and ask for a mech or hybrid, ask the right questions to determine whether they know what they’re doing. The first one is “WHY?” the answer to that tells you everything you need to know.
3: If a customer constantly comes in for you to re-coil a mech or hybrid device, do your very best to take their setup in part ex for something regulated and safe. Please.

Think about it.

This unfortunate happening has resulted in massive publicity, has certainly resulted in people dumping their ecigs and going back to smoking, and that is, in fact, a net lowering of your customer base.

We have to do everything we can to prevent such things happening again. If we don’t “they” will, and regulations no-one wants will ensue.

Researchers based in North Carolina have discovered that if you lie to smokers about the amount of harmful chemicals in e-cigarettes compared to traditional cigarettes you will put them off using the products. In a study entitled 'How hearing about harmful chemicals affects smokers' interest in dual use of cigarettes and e-cigarettes', Pepper et al present smokers with four scenarios and then analyse their attitude towards dual use of the products with smoking. The four scenarios were:

That cigarettes and e-cigarettes had the same amount of harmful chemicals

That cigarettes contained 10x more harmful chemicals than e-cigarettes

That cigarettes contained 100x more harmful chemicals than e-cigarettes

That cigarettes contained harmful chemicals and e-cigarettes contained none

Unsurprisingly, in the scenarios where e-cigarettes contained less or no harmful chemicals participants indicated that they would be more likely to initiate or increase dual use of cigarettes and e-cigarettes.

What isn't immediately obvious from the publicly available abstract, but is noted in the limitations section of the full paper hidden behind a paywall, is the fact that the study concentrated on those smokers who said they would start or increase their use of e-cigarettes without stopping smoking. So smokers who indicated that they would completely switch to the safer product were excluded. 

Astonishingly, the authors concluded that this apparent encouragement of dual use created by giving smokers accurate information on the relative numbers of harmful chemicals in the products would lead to a harmful continuation of smoking, and that therefore e-cigarettes "may not be able to be approved as a modified risk tobacco product on the basis of reduced chemical exposure alone because the public views information about lower chemical amounts as inherently related to reduced health harms". Paracelsus must be turning in his grave. The underlying suggestion in the conclusion to this study is that the FDA should consider hiding the the fact that e-cigarettes contain vastly reduced numbers and amounts of harmful chemicals when compared to smoking combustible cigarettes. 

It is deeply concerning, but unfortunately not surprising to those of us who regularly read the bilge coming out of certain parts of the world, that researchers should feel comfortable suggesting that lying to smokers about the relative risk of products would be a viable public health policy. The obvious consequence of such a policy is that some people who might otherwise have switched to a safer alternative will continue to smoke. It is unfortunate that these researchers appear to have completely ignored them. Whatever happened to ethics?

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