Stoppard on smoking, Pt. 2

Yes, smoking has benefits. Right now they come at an intolerable cost. The e-cigarette seems to provide the one with very little of the other.

Even when Tom Stoppard talks nonsense – and let’s not forget Stoppard was an early supporter of Rupert Murdoch – he often points to key issues. Keith’s citation of Stoppard’s witticism about how smoking makes sense since immortality isn’t an option anyway raises three of them:

1. Yes, none of us is going to live forever, and the length of a lifespan is only one argument in the objective function. It’s reasonable to trade off longevity against other goals. A life with a finite span can’t actually be “infinitely” valuable.

2. As an empirical matter, smoking does a lot more than shorten life. Smoking also damages health, so smokers’ lives are less pleasant as well as shorter than they would otherwise be. And no, the life-years aren’t all “taken off the end;” smoking roughly doubles mortality at every age.

3. Nicotine delivers substantial benefits along with its costs: it helps people calm down when they’re anxious and speed up when they’re lethargic. No other drug delivers those dual benefits. The e-cigarette, which delivers nicotine by lung but without doing so in a cloud of toxins, provides virtually all of the pleasures of smoking – except to those for whom the “flavor” of cigarette smoke is a secondary reinforcer via its Pavlovian association with the nicotine jolt – with a tiny fraction of the health damage. Sensible public policy would tax actual cigarettes to the point of extinction while pushing hard for e-cigarette substitution. But the tobacco companies and the anti-smoking crusaders are about equally hostile toward such a common-sense approach.

Footnote And no, I don’t think we should wait until someone has done the clinical trials. We know plenty about the health damage from nicotine alone, and the numbers aren’t impressive. And the e-cigarette delivers nicotine alone. Seems to me it’s up to those who claim it might be harmful enough to worry about to come up with some data.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: Markarkleiman-at-gmail.com

21 thoughts on “Stoppard on smoking, Pt. 2”

  1. A few years back, a study showed cigarette smoking provided a brief boost to IQ (a couple of points over a half hour to hour period).
    Now that I think about it, this study was probably done with smokers an could be seen in light of a reduced IQ from adicts being deprived. Hmmm?

  2. That’s what I thought, but apparently not. The study has been done on non-smoking kids with ADHD.

  3. I agree with your assessment that e-cigarettes could potentially be a viable substitute nicotine product and an important part of a harm reduction intervention based on pricing driven by taxes. My impression is that the products are not quite there yet in terms of consistent nicotine delivery and, what’s more, they are awaiting FDA action from its Center for Tobacco Products subsequent to Judge Leon’s rather odd ruling that categorized e-cigs as tobacco products rather than drug delivery devices. One must concede that the freebasing impact of nicotine from conventional cigarettes is not the same as other forms of nicotine delivery as far as our brains are concerned. Still, it may be good enough when the alternative is essentially unobtainable.

    Taxes, especially massive excise taxes that would make conventional cigarettes unobtainable except to the wealthy (who don’t smoke much) would be enormously unpopular. However, polling seems to indicate broader public support for FDA reduction of nicotine levels in conventional cigarettes to non-addictive levels to help smokers to quit and prevent youth initiation. The FDA has been granted clear authority to do this under the Family Smoking Prevention and Tobacco Control Act of 2009 (so long as nicotine levels are capped to any level above 0).

    It seems to me that approval of and low taxes on e-cigarettes and other nicotine alternatives combined with limits on nicotine content to non-addictive levels via FDA rulemaking is the most viable path to reducing most morbidity and mortality from cigarettes in the U.S.. It would be a provocative and politically polarizing initiative that would produce a myriad of unintended but manageable consequences. Such an intervention would likely be the most significant public health initiative in more than a century. It ought to be done within the next 5 years.

    1. I appreciate your assessment that e-cigs can potentially be a viable substitute for nicotine products- I suppose you meant smoking. I can tell you that for me, it already is. Also, he little e-cigs sold in gas stations and the like certainly haven’t reached any type of level of satisfaction unless you puff on them all day long (would take 10 batteries!!!). I have found a device (and there are many out there) that delivers through vapor enough nicotine to help me stay smoke free, so I cannot agree with you that the “it’s not quite there.” What I do, definitely is “good enough.” However, the main issue I have is with what you seem to be saying about cutting down the nicotine to a level that is not addictive. All e-cig users that I know were already addictive- so it’s too late. We need an alternative and at least at first, for most of us that’s an addiction to a less harmful way to ingest the nicotine. Besides, an addictive amount is different for different people and so there cannot be a blanket Mg dosage that can be said to be the “cut off” for addiction. Different people are addicted at different levels… So, I foresee your approach as one leading people to injest more and more nictotine or using a small c-cigarette with limited amount of nicotine, like a freight train, trying to get more and more out of it. I was much the same way when I started using an e-cig- my gums and teeth actually hurt trying to get more out of the small object…but I was sold on the concept and kept searching until I found a better devise and something more than a little cartridge. So, my question is, why regulate the levels- because it might be addicting? So what if it’s addicting- like I said, most of us are ex-smokers. We’re addicted already anyway. Oh, and you didn’t bring it up, but the idea that e-cigs might attract new “smokers,” is utterly unfounded. Kids for instance would rather smoke the real thing than to spend the money on some device and have to recharge batteries, mess with e-liquids and the like. Besides, not much in terms of harm has been found in plain nicotine ingestion anyway (we’re not talking about smoking), and it’s akin to drinking cups of coffee. If we get to much, we simply stop vaping our devices…we don’t feel well until the point of “getting to much” has subsided. For me who has switched to e-cigs after 30 years of 2 packs of smoking a day, the e-cig has been a godsend. I had tried every conceivable method to stop numerous times and this is the only thing that worked- and it worked within a week. Now, I have not smoked a cigarette in 18 months- I have absolutely no desire to smoke. That said, I started at 36mg/ml of nicotine. My body eventually told me that this was to much and I dropped to 24mg/ml..that’s only 2.4%. However, within a few months, I didn’t feel like that amount was right for me anymore and I dropped my levels again and now, for about a year I’m at 1.8% (18mg/ml)… I go through about 5ml of this liquid a day. When ever I have tried to lower the dosage, I have just used more…and then when I tried to cut back on quantity is where things got interesting. I would had trouble sleeping, concentrating, and getting things done. Anyway, my point is that nicotine has helped me and makes me feel normal. Upon looking back at my history of cigarette smoking, I can truly now say that part of why I smoked had to be some type of self-medication to keep my equilibrium. My parents tell me that when I was growing up they really didn’t have medication for what seemed to be my issues but in today’s world I would have probably been diagnosed with ADHD and put on Ritalin or some other psycho stimulant. I am a well educated man who works with other professionals, some who are in the medical field. Many of them have also switched to e-cigarettes. The use of e-cigarettes has nothing to do with morbidity or mortality, like actual smoking or combusting of tobacco does which includes ingesting tar and hundreds of other carcinogenic substances. Not only has my cognition been kept intact from using an e-cigarette, my health has greatly improved, including my dental health and my lung functioning. All of my health care providers are elated at my progress and some have recommended e-cigs to some of their other patients who they have not been able to convince to quit smoking or who have tried pharmaceutical approaches without success. So, that’s just my story and from personal use of e-cigarettes, I wanted to share what I know about how it “really” is in the real life use of them. If you would like to read up on some of the latest research (ie: vapor does not contain any harmful substances to the bystander, etc), please visit casaa.org This is not a paid, lobbying group- it is a group of volunteers, made up of folks who like me have quit smoking, either with e-cigarettes or by other less harmful means.

    2. “low taxes on e-cigarettes”

      Why do we need taxes (apart from sales tax) on e-cigarettes at all?

      1. I agree and certainly there should be no “sin tax” on them to help pay for smoking related illnesses like cigarettes…of course, not unless they can prove that they create health problem, which they haven’t.

  4. Yes. Although I hate the e-cig industry, and the spammers who push it, I’m fairly convinced that e-cig policy represents the biggest opportunity for harm reduction…ever. The University of Florida campus went “tobacco free” and lumped e-cigs in.

    1. I agree with you Steve…unfortunately, like every industry there are those that take advantage and are in it for the money only. I see this everyday and shake my head. It appalls me as one who is an e-cig user (actually, I refer to what I use as an AVD- advanced vaporizer device) that these guys are giving a wonderful invention a bad name. Still, if these substandard devices gets someone to quit smoking, I’m happy. Hopefully they will be sold on the concept and search out better products (as there are in every industry). It’s like if the care was just invented and big companies were pushing spam of a Yugo like car…day after day…you were sold on using a car rather than walking or riding a horse and discovered that for actually less money you could be driving a Volvo…

  5. As someone who works in the tobacco cessation field, I would strongly caution against current e-cigarettes. Though they probably offer fewer toxins than cigarettes, there is no guarantee that they are toxin-free. The ideal of a ‘nicotine-only’ delivery device would be a great harm reducer. E-cigarettes that are currently on the market, however, have not been proven to be nicotine-only.

    There is no regulation of the e-cigarette. When the FDA attempted to regulate the e-cigarette as a nicotine-delivery device, federal courts enjoined the regulations, finding that e-cigarettes are a tobacco product, not a drug delivery device. Until Congress amends the FDA’s purview to include the e-cigarette (or, more unlikely, the Supreme Court overturns the circuit decision), e-cigarettes will remain potentially toxic and a large risk factor to returning to ‘regular’ cigarettes. The relative availability of tobacco means that if a smoker is attempting to substitute the e-cigarette for their smoking habit, they are much more likely to relapse than if they are attempting to quit using FDA-approved adjunct pharmacotherapy and behavioral intervention.

    Another side effect of lack of regulation is that the e-cigarette is not a particularly consumer-friendly product. Smokers are very good at titrating their nicotine dosages while smoking tobacco. Novice users of the e-cigarette are less likely to dose themselves with the water-nicotine vapor available from the e-cigarette. The devices are also notoriously unreliable, failing to deliver consistent nicotine per puff.

    But yes, in an ideal world, smokers would vaporize pure nicotine instead of inhaling a toxic cloud. The technology and regulation, however, has not reached the point where the e-cigarette realizes this ideal.

    1. Is there any positive indication that current e-cigs are not nicotine free or is it just the lack of proof that they are?

      1. daksya,
        It depends on what you buy/get. I know for a fact that mine has nicotine in it…I make my own juice that goes in my devise. Some people have chosen to “vape” zero nicotine too. What you get in the stores have nicotine as indicated on the package. Also, depends on what country you live in. For instance in Japan, my understanding is that e-cigs w/ nicotine are not allowed to be sold…only imported from abroad. I hope that this answers your question. Otherwise, for a more in depth read on what’s actually in them, please see this: http://casaa.org/Electronic_Cigarettes.html

      2. Sorry, I may have misunderstood your question- maybe you were asking if “other substances” were in them or not…Oh well, the link in my previous reply should still get you some info on this.

    2. Three years ago, I had been smoking for 45 years. I learned the hard way that nicotine abstinence is not for me. The cognitive impairments made it impossible for me to even drive a car safely, much less do quality work as an instructional designer. Even though a combination of bupropion and as much nicotine gum as I could stomach without triggering acid reflux allowed me eventually to reduce the number of cigarettes per day to only 10, the lung damage was catching up with me. I was being kept awake at night by my wheezing, and I was coughing up a nasty lump of phlegm every morning. Trading in those last 10 cigarettes for use of an e-cigarette made a big difference in my lung health. Now, I only wheeze upon exertion, not while laying in bed. The morning cough is gone. I can laugh out loud without going into a coughing jag. Can you honestly tell me that you believe I would be healthier if I had kept smoking those 10 cigarettes per day for the past 3 years?

      You complain that there’s no regulation of the e-cigarette. How much regulation has been implemented on combusted cigarettes? Smokers who are serious about trading in their smokes for a less hazardous alternative scour the internet and find forums where they can get advice from more experienced users regarding what equipment works best. Those who had been struggling to give up those last few cigarettes while they tried to switch learn that there are higher nicotine concentrations available to help them escape all the way from inhaling smoke.

      As someone who works in the tobacco cessation field, you should think carefully about (in effect) advising smokers to just keep smoking for the time being. I’m convinced that if I had not traded my last 10 cigarettes for an e-cigarette three years ago, by now I would be dragging an oxygen tank around with me….assuming I wasn’t already dead.

      Older smokers don’t have any time to waste. They need to stop inhaling smoke ASAP, using whatever method works!

    3. Ben, I appreciate your post, but I’m a true, living red blooded e-cigarette user. I make my own liquids that I vape so I know exactly what is in them. There is nicotine, vegetable Glycerin, Propylene Glycol and natural flavorings (that are FDA approved)and that’s it. You might want to educate yourself in regards to the liquids that are used. If you are sincerely in this field, you had better know the facts: casaa.org I tried quitting for over 10 years (30 year smoker of 2 packs a day) w/ the pharmaceutical methods numerous times to no avail. I have quit smoking for 18 months now with the use of e-cigarettes and have no desire anymore to smoke. My health is much better now- thanks! There are devices out there that beat the little e-cigs sold in super markets and gas stations, hands down, so I agree with you if that’s what you’re talking about- unfortunately many of these devices cause many to give up on the concept of using an e-cigarette as a replacement for smoking. But you don’t know what you’re talking about if you think that that’s all there is because there are vaporizing devices that are reliable level and ideal. Go over to the Electronic Cigarette Forum and you’ll see tens of thousands of satisfied e-cigarette users. Currently, the e-cigarette industry is self-regulating. If there are bad products, we all know about them very quickly and people know to not buy them. What the FDA could do is look at the actual data in regards to them and make a break from their big pharma buddies (who are losing big bucks due to e-cigs) and allow a shift in their thinking- to admit to a Harm Reduction method to tobacco control and regulation. Certainly, the proper FDA approach would assure all of us that we are getting safe e-liquids and adequate devices- most of what the general public (unless they go on a search like I did) have no idea about…so they’ll keep buying the ineffective supermarket/gas station e-cigs which will cause them to go back to puffing on their cancer sticks.

    4. Federal court ruled that e-cigs should be regulated as tobacco products, not drug delivery devices. FDA decided not to appeal and to pursue regulations under its authority to regulate tobacco products. Manufacturing standards, nicotine disclosures, and safety assurances will be required as these devices are regulated as either nicotine replacement cessation products or modified risk products, depending on how manufacturers apply.

      1. Just because the same Obama appointed FDA officials who made false and misleading claims about e-cigarettes and who unlawfully tried to ban them in 2009 (and who have refused to correct, clarify or remove their fearmongering propaganda from the agency’s website) have stated their intent to propose a “deeming” regulation to apply Chapter IX of the FDCA to e-cigarettes doesn’t mean that its a done deal (as Mark Gottlieb claims).

        Chapter IX also requires that any new tobacco regulations must benefit public health, and there is zero evidence that applying Chapter IX regulations to e-cigarettes would benefit public health. In fact, since Section 910 would effectively ban the sale of all e-cigarettes that weren’t on the market in 2007, the deeming regulation would be a public health disaster that would primarily protect cigarette markets at the expense of the health and lives of several million e-cigarette consumers and tens of millions of smokers.

  6. “In an ideal world, smokers would vaporize pure nicotine instead of inhaling a toxic cloud.” But when a device comes along that allows smokers to vaporize pure nicotine instead of inhaling a toxic cloud, the “tobacco cessation field” rallies against it. There would be humor in this, if people weren’t dying.

    1. Well put- that’s the whole point in my opinion…something’s got to change!

  7. Smokers *can* now vaporise pure nicotine, by using an e-cigarette. Nicotine by itself doesn’t work, so a harmless diluent such as PG or glycerine is used. As the result is not entirely optimal, flavours are added. And there you have it: vaporised nicotine. All the ingredients are GRAS / Acceptably Safe, and in some cases have 70 years of safe use for inhalation.

    The UK is the only place in the world where e-cigarettes *are* regulated and permitted. They are inspected and analysed by the consumer products oversight authority whose job is to do exactly that (Trading Standards). So far the only issues noted have been the lack of CE approval certificates for some of the electrical components, which caused a recall for a very small number of units (for which no actual danger was shown). No toxic ingredients have been found despite extensive GC-MS testing. The products sold in the US are either identical or substantially similar, and should not arouse any cause for concern. After many year’s use, worldwide, by millions of people, with tens of millions of ecigs sold, not one instance of mortality or morbidity has been reported – a very fine achievement. In the same timescale, it might be noted, a quit-smoking medication introduced at the same time has killed hundreds (according to the FDA) and ruined tens of thousands of lives. E-cigarettes are therefore shown to be many thousands of times safer than Chantix, sometimes suggested as a ‘better’ alternative.

    Please also note that the average failure rate is 95% for quit-smoking pharmacotherapies and/or smoking cessation programs based on pharmaceutical interventions (i.e. what medics provide/prescribe). The success rate can even be as low as 2%. Tens of thousands of people try to quit and fail and fail and fail again. Instead of being condemned to death, perhaps one might permit them to use an e-cigarette if that doesn’t offend your sensibilities too much? Or maybe they should just go away and die?

    Incidentally the mini e-cigarettes sold by supermarkets are the entry-level beginner-grade starter devices. Polls tell us they satisfy 8% of users. The other 92% upgrade to something with better performance: the far more efficient mid-size and APV (big battery) models. The most popular devices in polls of experienced users are the mid-size units, which are about the size of a large cigar. People soon upgrade from a mini, once they see the potential.

  8. Hi, Mark. I think it has been a decade since I last talked to you. Judging from your wise comments (and as you undoubtedly realized from the comments from some of my friends and colleagues), there is a large very thoughtful community devoted to this issue (tobacco harm reduction). However, the average naive reader of the topic (a category that includes most of the people who read your writing) would never discover that because the anti-tobacco extremists so dominate the discourse.

    With that in mind, if you are at all interested in pursuing this topic further and want more material or whatever, please drop me a note.

    Thanks for pointing out that waiting for further research is a silly idea. I offer a friendly amendment to what you said, though, which is your use of “clinical trials”. As you of course know, clinical trials are not a useful way to study some topic. E.g., if we had to wait for the clinical trials, we would have no anti-smoking policy, because there are not, nor ever will be, particularly useful trials of smoking. So we should realize there never will be useful clinical trials (except about short term effects and biomarkers, and then it will just be about a few products that might not even be on the market anymore when the study gets published). But we should not wait for the *epidemiology* in general, pretending that we know nothing.

    Finally, it is worth mentioning that the reason we know that nicotine sans smoke is so low risk (undetectable) is because of use of smokeless tobacco, which we have had a chance to study for decades. Thus, whatever policies you recommend for e-cigarettes (i.e., no excise tax) apply even more so to smokeless tobacco, since that is the primary source of our knowledge and e-cigarettes are an extrapolation thereof.

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