November 28th, 2015

A billion lives?

A promising new documentary film is on the way to our screens: A billion lives –“a true story of government failure, big business and the vaping revolution”. See trailer above.

It gets its name from the often-quoted figure that one billion lives may be lost to diseases caused by smoking in the 21st Century.  The eminent epidemiologist Sir Richard Peto summarised the outlook in a comment to the Independent newspaper: Smoking will ‘kill up to a billion people worldwide this century’ (8 Nov 2012)

Sir Richard Peto of Oxford University, a co-author of the Million Women study who worked closely with Sir Richard Doll, is also the scientist who first calculated how many people this century will die from tobacco-induced cancers. “We have about 30 million new smokers a year in the world. On present patterns, most of them are not going to stop, and if they don’t stop, and if half of them die from it, then that means more than 10 million a year will die – that’s 100 million a decade in the second half of the century,” said Professor Peto.

“So this century we’re going to see something like a billion deaths from smoking if we carry on as we are.

But where do these numbers come from?

So, it starts with the idea that smoking is a cause of serious disease and that people die from it – and they would die later without it. So, in a given year, they have a higher probability of dying (or being already dead). The diagram below, from the famous study of British doctors, is one way of showing that – the probability of living to a given age after age 35. There are some differences between men and women and in different countries.

Doctors

Doll R, Peto R, Boreham J, et al. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ 2004;328:1519 [link]

So, this particular study showed that 81% of men who never smoked make it to 70 but only 58% of continuing smokers. Or put another way, the median smoker loses about 10 years of life between 73 and 83, and about 20% lose 10 years between 60 and 70.

Note that some of this increased probability of earlier death may arise from other things that smokers do more or less of.  For example,  if they take less exercise or do more drinking that might also contribute to shifting that blue curve to the left, for example by dying of liver disease. So these curves are plots of premature death representing the average lifestyle of those studied – doctors in this case. However, most of the difference is down to smoking itself.

Stopping smoking reduces risk. The good news from this study was that “cessation at age 50 halved the hazard, and cessation at age 30 avoided almost all of it.” You can see graphically how stopping smoking at different ages changes the probability of early death here.

cessationimpact

They obviously do not mean by this: “smoke your head off until 30, then quit and you’ll be fine” – many people who smoke until into their 30s may not find it easy to quit, and may not want to try. But I think with vaping available as an option to eliminate nearly all the risk of recreational nicotine use, a major focus of tobacco policy should be on encouraging, or merely not obstructing, middle-aged adults who cannot  or choose not to quit using nicotine to switch from smoking to vaping as rapidly as possible. This means that millions, perhaps hundreds of millions, of premature deaths might be avoided if smokers switch or nicotine users never smoke in the first place.

How these numbers are not calculated. A real problem with counting premature deaths is that smoking may reduce the length of nearly every smoker’s life, even by a few days or minutes, compared to living exactly the same life and never having smoked.  Do they all get counted in the premature death toll? No. Actually, that is not how these calculations are done.

How these numbers are calculated. The approach taken is to look at the main diseases that cause death in smokers (cancer, cardiovascular and respiratory) and then work out how many of the deaths caused by those diseases can be attributed to smoking. The clearest case is lung cancer, where the risk for smokers is about 20 times higher than for non-smokers.  So you can look at how many deaths there are from lung cancer, how many smokers there are and then work out how many of the deaths are due to the excess risk created by smoking and how many would have happened anyway. With a few additional complexities for ex-smokers, differences for men and women etc out comes the number of lung cancer deaths attributed to smoking. Then with even more numerical dexterity, numbers can be calculated for other diseases.

When making projections of future smoking-related deaths, several other things are needed.  For example, some way of characterising assumptions about smoking – and how that translates to disease outcomes – often with a lag between the behaviour and the disease.

Smoking-Cancer

So, some future disease arising from past smoking is already in the system: it may take 50 years for the full consequences of arise in smoking to work through to disease outcomes.

A typical pattern in developed countries from the 1940s is that fewer women ever smoked, and female smoking prevalence peaked later and then converged with male prevalence.  This is very different in developing countries, where female smoking has been much lower. But will it stay that way?

LungCancerSmoking

We can work through the technique above.  So start with the observed cancer deaths.  For example, these UK figures:

Screen Shot 2015-11-25 at 16.44.31

If we know smokers are more likely to get lung cancer than non-smokers, we can look at the total lung cancer deaths in a population and decide how many of these are additional to what there would be without smoking. The share of this cancer that is attributed to smoking is known as the “Population Attributable Fraction”.

Key concept: the “Population-Attributable Fraction (PAF) [WHO definition]:

Population attributable fraction (PAF)… is the proportional reduction in population disease or mortality that would occur if exposure to a risk factor were reduced to an alternative ideal exposure scenario (eg. no tobacco use)

The U.S. Surgeon General 2014 report explains how it works here, and various different methods are reviewed here. If you want the equations, they are at these links.

The method involves using the estimate of relative risk of premature death from a disease that has been found large cohort studies.  Cohort studies follow a group of people, track what they do (e.g. smoking) and check what fate befalls them. Relative risk is the ratio of the probability of smoker dying of a disease to the probability that a non-smoker will die from it. A high relative risk can mean it is highly likely in smokers or very unlikely in non-smokers (e.g. lung cancer). A low relative risk means there may be many other causes in smokers and non-smokers (e.g. cardiovascular disease caused by diet or physical inactivity).   These relative risk estimates are used to attribute the observed deaths from, say, lung cancer, to those caused by smoking and those that would have occurred anyway – giving the PAF.

The biggest of the cohort studies is the American Cancer Society Cancer Prevention Study II (CPS-II) – and from this study much of the estimation of risk and premature death for smoking is derived.  It is not just used for cancer but other diseases too, and not just for the U.S.  This is how the relative risks turn out for the CPS-II cohort – see table

CPS - II -relative risks

Relative risks for adult mortality from smoking-related diseases, adults 35 years of age and older

In the case of the chart above, the application of these techniques to attribute cancer deaths to smoking comes out as follows for the UK, separated for men and women:

Screen Shot 2015-11-25 at 16.44.55

If these figures are totalled for different countries, the burden of smoking-related cancer can then be estimated.

For other populations and diseases. There are huge assumptions and approximations built into using the CPS-II cohort to estimate relative risks for different populations – e.g outside the U.S. or in future. In much of the work that uses these data, conservative assumptions are made (like halving the relative risk) to take account potentially lower relative risks in different populations.  Some clever techniques are used to fill in blanks in data. For example, because lung cancer is known to be relatively rare in non-smokers, it is possible to infer previous rates of smoking from current lung cancer rates. But note the use of conservative assumptions in doing so…

Even in the absence of direct information on smoking histories, therefore, national mortality from tobacco can be estimated approximately just from the disease mortality statistics that are available from all major developed countries for about 1985 (and for 1975 and so, by extrapolation, for 1995). The relation between the absolute excess of lung cancer and the proportional excess of other diseases can only be approximate, and so as not to overestimate the effects of tobacco it has been taken to be only half that suggested by a recent large prospective study of smoking and death among one million Americans. [link]

Understanding the past and present

The pioneering work on this was done in the 1980s and early 1990s. A substantial resource of mortality projections is maintained at Oxford University: Deaths from smoking.   The initial focus of research was on developed countries.

Peto R, Boreham J, Lopez AD, et al. Mortality from tobacco in developed countries: indirect estimation from national vital statistics. Lancet 1992;339:1268–78. [link][PDF]

At present [1992] just under 20% of all deaths in developed countries are attributed to tobacco, but this percentage is still rising, suggesting that on current smoking patterns just over 20% of those now living in developed countries will eventually be killed by tobacco (ie, about a quarter of a billion, out of a current total population of just under one and a quarter billion)

Peto R, Lopez AD, Boreham J, et al. Mortality from smoking in developed countries 1950−2000. 2nd Edition. [link] – showing about 2 million smoking-related deaths in developed countries in 2000 – but also the age stratification, with smoking accounting for 30% of male deaths before 70.  (Annotation added to show ~2m).

deaths
We start to see studies that look globally.

Ezzati M, Lopez AD. Estimates of global mortality attributable to smoking in 2000. Lancet 2003;362:847–52 [link] –

We estimated that in 2000, 4·83 (uncertainty range 3·94–5·93) million premature deaths in the world were attributable to smoking; 2·41 (1·80–3·15) million in developing countries and 2·43 (2·13–2·78) million in industrialised countries. 3·84 million of these deaths were in men.

Ezzati M, Henley SJ, Thun MJ, et al. Role of smoking in global and regional cardiovascular mortality. Circulation 2005;112:489–97.[link] – take a global view and focus on cardiovascular mortality.

Conclusions— More than 1 in every 10 cardiovascular deaths in the world in the year 2000 were attributable to smoking, demonstrating that it is an important preventable cause of cardiovascular mortality.

Predictions about the future

Niels Bohr

There are numerous obvious difficulties projecting forward. Projections require assumptions about future uptake, smoking cessation rates, population size, and treatment for smoking-related diseases that may reduce mortality. There are also some weird effects to consider: as a country grows richer, the risks of dying from other diseases, accidents or violence may decrease, making it more likely a smoker will live long enough to die from a disease caused by smoking.  This effect was visible in the doctors’ study mentioned above.

Furthermore, behaviours will all depend in part on policy assumptions – like taxation, marketing restrictions, effective quitting aids etc – and availability of alternatives.

So I would take all future projections as ‘order of magnitude’ approximation that is entirely contingent on assumptions. Here is one example of uncertainty, the population:

World population

We also have to make assumptions about what will happen to smoking prevalence in future. For example, if Chinese smoking followed the pattern in Europe or U.S., we would expect to see female smoking rising to meet male smoking as it comes down. Mercifully, this is not happening. [link].

Chinese men now smoke more than a third of the world’s cigarettes, following a large increase in urban then rural usage. Conversely, Chinese women now smoke far less than in previous generations.

The one billion deaths figure

The rough ‘consensus’ emerging from these studies is smoking-attributed-mortality was about 5 million/year in 2000, and will rise to about 10 million/year by 2030, with a total death toll of about 450 million accumulating by 2050. If this carries on after that date at about 10 million per year or slightly rising, the one billion figure is reached by 2100.  That’s a scenario or projection, not a forecast, because it depends on trends continuing and lots of assumptions about the future.

Nevertheless, this what a few of the studies have concluded.

Doll R, Peto R, Boreham J, et al. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ 2004;328:1519 [link]

The general statement that in many very different populations the future risk of death from persistent cigarette smoking will still be about one half is therefore a reasonable one, and the results thus far in a widening range of studies in other developed and developing country populations such as China and India seem consistent with it (as long as the prolonged delay between cause and full effect is properly appreciated). If so, then on current worldwide smoking patterns (whereby about 30% of young adults become smokers) there will be about one billion tobacco deaths in this century, unless there is widespread cessation.

Jha P, Peto R. Global effects of smoking, of quitting, and of taxing tobacco. N Engl J Med 2014;370:60–8 [link] also view the [supplementary appendix]

On the basis of current smoking patterns, with a global average of about 50% of young men and 10% of young women becoming smokers and relatively few stopping, annual tobacco-attributable deaths will rise from about 5 million in 2010 to more than 10 million a few decades hence.

Jha P, Chaloupka FJ, Moore J, et al. Tobacco Addiction, Chapter 46 in Disease Control Priorities in Developing Countries. 2nd edition, 2006. [Link]

Cigarette smoking and other forms of tobacco use impose a large and growing global public health burden. Worldwide, tobacco use is estimated to kill about 5 million people annually, accounting for 1 in every 5 male deaths and 1 in 20 female deaths of those over age 30. On current smoking patterns, annual tobacco deaths will rise to 10 million by 2030. The 21st century is likely to see 1 billion tobacco deaths, most of them in low-income countries. In contrast, the 20th century saw 100 million tobacco deaths, most of them in Western countries and the former socialist economies.

Jha P. Avoidable global cancer deaths and total deaths from smoking. Nat Rev Cancer 2009;9:655–64.[link]

On the basis of current consumption patterns, approximately 450 million adults will be killed by smoking between 2000 and 2050. At least half of these adults will die between 30 and 69 years of age, losing decades of productive life. Cancer and the total deaths due to smoking have fallen sharply in men in high-income countries but will rise globally unless current smokers, most of whom live in low- and middle-income countries, stop smoking before or during middle age.

And most recently, an in-depth analysis of smoking in China, looking at current mortality and the trend.

Chen Z, Peto R, Zhou M, et al. Contrasting male and female trends in tobacco-attributed mortality in China: evidence from successive nationwide prospective cohort studies. Lancet 2015;386:1447–56. [link].  Here you can see where large numbers in developing countries emerge. China now has about one-third of the world’s smokers and as this century progresses more of them will be dying from smoking.

Smoking will cause about 20% of all adult male deaths in China during the 2010s. The tobacco-attributed proportion is increasing in men, but low, and decreasing, in women. Although overall adult mortality rates are falling, as the adult population of China grows and the proportion of male deaths due to smoking increases, the annual number of deaths in China that are caused by tobacco will rise from about 1 million in 2010 to 2 million in 2030 and 3 million in 2050, unless there is widespread cessation.

Conclusion

  • Smoking over several decades does substantially raise the risk of cancer, cardiovascular and respiratory disease, and of dying prematurely as a result. It is possible to put numbers on these deaths.
  • The global burden of disease is now rising rapidly as the effect of rising smoking and growing population in developing countries is working through to have its impact on population health.
  • It is a daunting task to estimate the historic or current global death toll attributable to smoking, and it requires many approximations, assumptions, and workarounds where data is poor or non-existent.  However, statisticians do try to make cautious assumptions.
  • Projecting future death tolls depends on further unknown or unknowable quantities and, therefore, on further assumptions and approximations.
  • Most figures quoted for future deaths are scenarios or projections rather than forecasts and most assume current trends continue.
  • With all the caveats above, it is not unreasonable to say that, on current trends, about one billion lives will be ended prematurely by diseases caused by smoking in the 21st Century.
  • This one billion deaths figure, if it came to pass, would be a dire failure for public health. Its purpose is to identify policies that work and are acceptable in terms of cost-effectiveness, intrusiveness, equity etc to alter these trends and to reduce the harm done.
  • If several hundred million people take up vaping instead of smoking, or switch from smoking to vaping mid-life, and if vapour (or equivalent) products start to obsolete cigarettes for many or most users, there is the potential to avoid hundreds of millions of unnecessary premature deaths. This should be a public health ambition and not something to fight against.
  • This strategy is promising because it goes with the grain of consumer preferences and does not require public spending, coercion or punitive and regressive measures – or the massive unintended consequences of prohibitions or excessive regulation.
  • This strategy does require public health and tobacco control practitioners to do the following: to stop misleading smokers about the risks of vaping; to stop pretending there are adverse population consequences – there is simply no sign or likelihood of adverse effects; and to stop campaigning for policies that protect the cigarette trade and implicitly promote smoking.
  • I hope and expect the film A billion lives will explore some of these issues.

Further reading

Carl V. Phillips has done a very nice series of briefings on where these numbers come from – and what they do, and do not, mean:

Postscript

Curiously, in July 2015 the World Health Organisation removed the one billion figure from its factsheet on tobacco. It was there in the May version.

27 comments to A billion lives?

  • […] Bates C. A billion lives? The Counterfactual, November 2015 [link] and Bates C. Are we in the endgame for smoking? The Counterfactual, February 2015 […]

  • Anonymous

    Hate to say, earth is massively overpopulated. Could be a form of culling.

  • […] This particular study showed that 81% of men who never smoked make it to 70 but only 58% of continuing smokers. Or put another way, the median smoker loses about 10 years of life between 73 and 83, and about 20% lose 10 years between 60 and 70. The good news from this study was that “cessation at age 50 halved the hazard, and cessation at age 30 avoided almost all of it.” (A billion lives?) […]

  • Irish Lass

    I think statistics can be useful, when not misused (as they so often are) to justify a position without regard for the truth. I was interested in how the “deaths from smoking” are arrived at. I don’t pretend to be an expert in statistics – far from it! – but it seems to me that (a) “deaths” is misleading, since we all die of something, sometime, and it seems that all the statistics show is that smokers have a somewhat higher risk of dying a bit earlier than is normal from certain diseases; and (b) there is some uncertainty as to whether these earlier deaths are actually due to smoking.

    However, that said, I think anyone with a titter of wit realises that (first-hand) smoking is not very good for you and is, therefore, better avoided if at all possible.

    Therefore, since there is now good cause to believe that vaping is MUCH less harmful than smoking, public health should be championing e-cigs. And in the UK there is some movement by public health in this direction (thank you to Public Health England; and thank you to Louise Ross). In other countries – notably Australia and the USA, – public health seems to have been hijacked by jumped up non-scientists who have more influence over politicians than they should.

    Tobacco control is another story.

  • vapingpoint

    What clears the fog about Tobacco Control is to realise it’s a new Industry that employs millions of people worldwide. It’s a parasitic industry bent on its own survival feeding off host governments. It’s not the only new Industry – parasitic ones I mean. They work for “the good of the people”,”for the future” “for the greater good”. The morality of what they do keeps them proselytizing, and converting others to feel noble too.

    “If you want a picture of the future, imagine a boot stamping on a human face—forever.”

    “Everything faded into mist. The past was erased, the erasure was forgotten, the lie became truth.” George Orwell 1984

  • John walker

    Clive
    Thank you!
    The case for smokeless products is overwhelming, if you look at the evidence and read the argument. Unfortunately a significant section of the anti smoking movement has become an ideology: hostile to facts argument etc.
    Can only pray that ” honeybees will come and build their nests in the empty house of the stare’.

  • Russell VR Ord

    Statistics can only spark and inform Scientific debate and encourage REAL Scientific experiments to take place. Unfortunately, the REAL Science is bypassed because it costs too much (or is undesirable), so the Statistics translate into science that is USED to justify a position in a debate. Without REAL Science (objectivity), all the arguments mean ‘nowt’.

  • Russell VR Ord

    Statistics are just that, they are NOT Science. Using statistics rather than Science to inform people is the norm in 2015. Most people will believe them and help spread the misinformation – the ultimate aim is not about Health, it is about Control. No matter how you try to use ‘studies’ based upon collecting information, it is NOT Science unless ALL other factors that may affect the result are controlled by the person conducting the ‘experiment’. The tobacco control ‘experiment’ (unscientific bullshit) is being believed – that means the end of REAL Science having an impact on legislators and the end of ALL ‘undesirable’ lifestyle choice – They will be picked off one by one.

    • Clive Bates

      Statistics let us understand, approximately, mass phenomena that would be difficult to understand quantitatively without them. It is a sophisticated branch of science, not an alternative to it. Stats are used, and abused, in any policy debate and just about any other debate.

      My own view is that most people decide what they believe based on moral (or moralising) instincts and then look around for reasoning to support it. To that end, they will draw on their own selective reading of statistics, science, economics, philosophy, anecdote, folklore and often just authority to back what they already know.

      I agree there is a large amount of very poor and ideologically motivated work in the field of tobacco control, and it does not have an adequately disciplined or challenging intellectual culture that would weed this out at source.

  • vapingpoint

    Trouble is, since the demonisation of smokers, any believable statistics of how many people ACTUALLY smoke is impossible I should think.

    I have really enjoyed sifting through the “Deaths from Smoking” link you posted – especially – Mortality from Smoking in Developed Countries 2nd Edition.

    I notice a strange “blip” in 1965ish/1970 or thereabout on all the graphs in increased deaths from all causes. I wondered if it could be all the atomic testing in the ’60’s? especially noticeable in Australia and New Zealand. (But Japan is completely different – magnificent in fact! Wonder what their secret is – different reporting I should think?and Poland and Switzerland likewise) Most countries show the “blip” that have stats…this is not a trick question, because the “blip” can’t be attributed to smoking/not smoking as it rises and falls directly. Just a thought.

    (Ed. broken link fixed]

  • Iro Cyr

    I do not have much more time to spend on this either, but you have more or less excused the Billion Lives exaggerations on posting your explanations here, you have more or less excused the SHS lies in Dick’s blog, all the while admitting to me this: ”I’m the first to agree that better measures of smoking prevalence are needed – especially in characterising ‘dual use’ of smoking and vaping, which can cover such extremes that the single categorisation is meaningless.” Yet at the same time you have no qualm over the film which perpetuates lies derived from meaningless single categorizations of smoking. I respect that this is not what your fight is about, however in your quest to reduce risks through the acceptance of vaping, you are excusing and perpetuating figures that you admit to being meaningless generalizations. Vaping can stand on its own merits as a risk reduced product without piggybacking on the Anti-Tobacco Industry propaganda in the process.

    • Clive Bates

      I don’t think the one billion figure is wrong, as I’ve explained at length its origin – which covers the things you are concerned about. I didn’t excuse the secondhand smoke numbers – I’m very sceptical about them. I did say you can hardly blame a film director for quoting a study published in The Lancet. This is what I actually said on Dick Puddlecote’s blog:

      The filmmakers can’t really be blamed for relying on a statistic originally published in a prestigious medical journal like The Lancet. But that doesn’t make it a reliable number, of course.

      It is very hard to believe this stat. The authors themselves provide a beginner’s guide to how weak this study is:

      “These limitations include uncertainties in: the underlying health data; the exposure data; the choice of study population (particularly the exclusion of potential effects in smokers); the effect sizes and their transferability to other populations and exposure conditions; the burden of active smoking (deduced from the total burden before estimation of the burden from second-hand smoke); and the susceptibility of ex-smokers”

      To this can be added doubt at every step in the chain of reasoning:

      1. that ‘exposure’ is characterised by having a parent who smokes, with no insight into how much or where – all of which would be near-impossible to characterise given the available data.

      2. that standard factors were used to convert exposure to risk – originating at WHO, Cal-EPA and US Surgeon General.

      3. that mortality from respiratory illness, especially in poor countries, can have multiple simultaneous causes (e.g. other sources such as indoor stoves, weakened resilience due to other illness, poor healthcare). The population attributable fractions are pure fiction.

      If that is excusing or perpetuating these figures, then I’m afraid we will have to disagree.

  • Clive Bates

    Sorry, what I meant was “I can’t justify spending any more time on it”. I’m very happy for everyone else to debate it. I spent a few hours doing this post to explain where these numbers come from and provided a lot of links and commentary, which I hope was helpful. I don’t think these are exaggerations if the numbers are understood correctly – the purpose of my post.

    I’m not sure what gross exaggerations I’m meant to be condoning or which lies I’m excusing – can you point to something I’ve actually said?

    Clive

  • Iro Cyr

    Clive, thanks for the links, I will have a close look at them but with all due respect I have to take issue with your ”not worth” going into. It’s all very noble to say that you in principle believe in freedom of choice, but much less noble to turn a blind eye to such grossly exaggerated anti-smoking propaganda because you believe that the ends justify the means, if I understood correctly. You as many other ”well-meaning” activists are forgetting that these gross exaggerations affect the everyday lives of millions of people. What with the nocebo effect it creates, what with psychiatric patients, old age people in their nursing homes, palliative care and long term patients in hospitals being deprived of their lifetime enjoyment and medication in certain cases, what with family and friend relationships being jeopardized, what with the isolation and demonization of smokers, what with the economic harm smoking bans have caused, what with public health losing all credibility to the point that people have stopped believing what could even be true not only with smoking but other health issues as well, I find it deplorable to think that it’s not worth denouncing such grossly exaggerated harms smoking causes or at the very least to stop perpetuating them through films such as A Billion Lives. By all means, continue leading the fight FOR vaping, but please do not excuse the rest of the lies because you do not feel that they are worth exposing. Worth has a different a meaning to each one of us and every lie is worth exposing when it affects millions of people.

  • All these estimates, hypothesis, models etc. may look reasonable in theory to academics, but when compared to table 2 in this link http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5644a2.htm , a table based on real people with real diseases giving real answers as opposed to computer estimates using risk factors as their base model, ”smoking related” diseases occur more often in former and never smokers than in current smokers. I would have no qualm with the sound bite that smoking kills half of its users prematurely if the former smoker category in this table only included anyone who was smoking more or less heavily and quit in the last let’s say 10 years because I would tend to presume that it was too late to reverse the damage that smoking allegedly caused them. But if you look at the footnotes of the table, these figures include anyone and everyone who has smoked at least 100 cigarettes in their lifetime. In theory then, it includes people who have smoked as little as 5 packs, quit before their 30’s and yet contracted a ”smoking related” disease in their 60’s 70’s or 80’s. I hope that you will agree that it is unlikely and unreasonable to blame such diseases on their smoking and lump such people in the ”smoker casualties” category when touting that lung cancer for example, occurs in smokers 80 or 85% of the time or that tobacco will kill half of its users.

    If we look at the ”current smokers” category now, it is just as unreasonable to include smokers who have smoked but one or two cigars or cigarettes per month since their 20’s , they are over 35 now, still smoke on occasion and contract a disease that will be lumped in the ”smoking related” disease category which is exactly what the Tobacco Control industry does when it touts morbidity and mortality figures for public consumption.

    This is the main reason why I refute and will continue refuting until proven in real life models that a ”Billion Lives” rests on credible grounds even if only hypothetical.

    • Clive Bates

      Of course, you are mostly right about people who just smoke a little… and that doctors’ study found no excess premature mortality in smokers stopping in their 30s. So that could have meant 15 years of regular smoking. The figures of 1 in 2 smokers dying early relate to continuing regular smoking right through life, and include deaths from smoking related diseases in the quite elderly – i.e. among the over-70s. There are some conditions – cardiovascular – for which there is a non-linear relationship between consumption and disease, so even quite low levels of smoking may be harmful.

      I’m the first to agree that better measures of smoking prevalence are needed – especially in characterising ‘dual use’ of smoking and vaping, which can cover such extremes that the single categorisation is meaningless.

      Clive

      • Iro Cyr

        The Tobacco Control Industry should be prompted by well-meaning and honest activists to drop the defeatist ”no safe level of smoking”, which is what their whole for public consumption propaganda is based on. I haven’t really gone into depths with the cardiovascular disease safe levels but surely if analyzed with a magnifying glass there must be flaws in there as well because this is not what real life is showing us, plus strokes are much more prevalent in never smokers than in current smokers and almost at par with current and former smokers combined, but I have read that it takes on average 280,000 inhaled cigarettes before and if cancer develops. That defeats the much touted ”no safe level” mantra at least for cancer, and where does it leave the fear mongering on second hand smoke which thankfully Mr. Biebert now tells us he removed from his film?

        • Clive Bates

          To be honest, I don’t think it is worth going too deeply into all this. It is pretty well established that smoking is harmful to those who do it – it would be amazing if it wasn’t, given what’s involved. It’s also pretty clear that people like it or are dependent on it, or some combination of the two – and I make no judgements about this. If there is a way that people can get what they like or need but without getting sick, then there’s scope for a public health win (that’s my agenda).

          On cardiovascular risks, the U.S. Surgeon General describes in depth:
          http://www.ncbi.nlm.nih.gov/books/NBK53012/

          For the non-linear dose-risk relationship, see this:
          http://www.ncbi.nlm.nih.gov/books/NBK53012/figure/ch6.f3/?report=objectonly

          There may be more strokes in non-smokers because there are more non-smokers, but the relative risk for a smoker is higher (~1.5 but age and gender specific).

  • LVD

    Slowly killing themselves is a matter of choice and personal freedom. But how many will die prematurely from second, third and fourth hand smoke? Those numbers are much more important to politicians in order to decide whether or not to pester smokers even further. The responsable side of PH is pretty silent about it and the irresponsible side is just making things up as they go along (as usual): 150 000 children a year die from second hand smoke. Really? Children developing a second hand or third hand smoke related lung cancer at the age of 7 is not very consistant with the smoker who started at the age of 15, quits at the age of 30 and sees no ill effect of 15 years of active smoking.

  • Matt C

    My government wants me to die after I have paid them to live. Systematic murderers. No government really wants a billion extra people to live. The TPD is their way of indirectly killing smokers.

  • Jude

    The problem with all these sorts of calculations and predictions, is that there are an infinite number of possible futures, war could kill huge numbers, a nuclear accident could destroy the world, an asteroid could hit the Earth, a new virus could wipe out millions, poverty could lead to the deaths of millions etc etc.

    Human beings are pretty powerless to change anything, so we look at ways of making ourselves feel secure, by focusing on one small element that we think we can change. The mistake we make is thinking that we have the right to force those changes on others.

    • Clive Bates

      I basically agree with you on this…people should do what they can and want to do to look after themselves. Governments, regulators, health organisations, however, can shape the environment for that. The reason to talk about one billion lives is that these bodies are approaching their responsibilities as if they are running a third rate circus and have no idea or concern about the consequences – and these figures show sheer scale in total is enormous.

      Their starting point should be not to intervene at all unless they are pretty certain it will improve people’s lives and in a way that does not deny them choices to take individual actions you mention.

      • Jude

        Unfortunately Clive when money and control over others is involved, there are certain types of people that take advantage of this. There are people that will never be satisfied in just letting others live their lives without intrusive intervention, particularly when their status and income depends on controlling others to do what “they” want, rather than what is best for the person in their own view. In the case of people like Simon Chapman, his self image, love of power, and basic narcissism, is a perfect example of the type of person that flocks to organisations like the tobacco control industry.

        This is particularly bizarre when we look at how governments put extortionist taxes on tobacco, then pretend to care, (via their tax funded lobby groups posing as public health or charities), about getting people to quit. At the same time banning the most effective way for people to quit and criminalising those that want to quit by switching to vaping. This is what is taking place right now in Australia. This utter hypocrisy is what I’m hoping the “A Billion Lives” documentary will shine a light on. There is a prevalent ideology that ignores science, and bases policy on what will keep those currently in positions of power and wealth, right where they are, smokers, vapers, or any other persecuted minority, be damned. This is the reality we live in, a reality where government/corporate funded lackeys will make up any old statistic, or create any old scare story and junk science, to keep the status quo.

  • vapingpoint

    Most useful post! Thank you.

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