Interview with tobacco control advocate David Sweanor

David Sweanor: I have been interested in issues of public policy and public health from a very young age, and trying to deal with the devastation of cigarette smoking combined those interests. I started doing volunteer work on the topic in the late 1970s, and joined the staff of the Non-Smokers’ Rights Association in 1983 as the first lawyer in the world working full time on tobacco control. The executive director was Gar Mahood, and he was one of precious few people who saw the smoking epidemic as a political fight. We likely drove each other mad(der) but we changed the world, and we had a lot of fun doing it. It seemed obvious even then that while figuring out what caused ill health was a medical/scientific pursuit, dealing with it was a legal/political one.

We combined being methodical and being creative in tackling smoking. We had to get our facts straight, build credibility for the movement, understand political and legal systems and act as advocates rather than bureaucrats. We were analogous to a commando group rather than a standing army. We could act quickly and creatively, blindsiding the bureaucratic cigarette companies on an ongoing basis.

We were able to achieve many precedents that ultimately greatly shaped global tobacco control efforts. The use of tax policy stands out (we knocked daily smoking among 15-19 year olds from 42% to 16% in only a few years based largely on successful tax campaigns). But we also achieved ad bans, graphic package warnings, smokefree policies in public areas, workplaces and aircraft. We banned vending machines and cigarette sales in health care institutions, and we held cigarette companies accountable for malfeasance, among other things. Something that many people do not recall is that harm reduction was long a component of these efforts, and section 17(1) of our national Tobacco Products Control Act passed in 1988 was explicitly about encouraging lower risk alternatives to cigarettes. At the time I think tobacco control was following a standard public health model where harm reduction is simply part of what one looks at. Interestingly, it was the cigarette industry that killed that provision in a constitutional challenge.

I think tobacco control changed as the field became far more bureaucratic and lost the creativity that had previously made precedents so much easier to achieve. Part of that transformation included the rise of some people who see this as an absolutist campaign against nicotine (or consumers, or capitalism...) and with a fundamentalist tinge. It concerns me when people grab onto and (mis)quote from the FCTC the way some religious fundamentalists do with scripture.

All my career I have focused on the fact that there are just four broad areas of intervention when we seek to reduce death, injury or disease. We do things

1) to prevent people from ever engaging in the activity,

2) to get those already engaging in the activity to stop,

3) to protect third parties from adverse effects from the activity,

and 4) to reduce risks for those who still engage in the activity.

These four are like the four suits in a deck of cards in a poker game. They interact and create synergies, and the failure to consider using one leads to far less success. In the case of smoking, we have had many great successes, but the woeful success rate at changing dissonant smokers into ex-smokers is due to a failure to play that fourth suit.

As others shy away from using a more comprehensive public health approach, that is where I spend ever more of my time and energy. Simply put, ‘that’s where the lives are’. Besides, I’ve been around long enough, am financial independent, and can take risks that might be hard for others to contemplate.

David Sweanor: I think there is much progress being made. We have gone from 150 to over 500 attendees in only a few years. But progress is still much too slow. After all, there are 20,000 people dying each day now from cigarette smoking. They are dying not due to the nicotine but to the inhalation of the smoke, and we can make cigarettes obsolete. We need visionaries. We need pragmatic revolutionaries. I see such people in ever increasing numbers at these conferences.

I have long seen public policy campaigns as being like hiking up a mountain. As we look at where we are trying to get it can feel daunting. So, we also look back to see how far we have come. Sure, many agencies that should be laser-focused on reducing cigarette smoking are instead unwittingly protecting cigarettes from disruptive technology that has the potential to be as important to public health as was the eradication of smallpox. But at the same time, we are seeing dramatic moves away from cigarettes virtually whenever consumers are given an opportunity. We have seen this play out in Sweden, which has (by far) the lowest rates of smoking and tobacco related diseases among wealthy countries. But now there is far more.

The dramatic switch from smoking to vaping in the UK, the huge fall in cigarette smoking and sales in France, the 30% reduction in cigarette sales in Japan with the introduction of heat-not-burn products, Norway reducing smoking prevalence by half in a decade with the widespread availability of snus , Iceland reducing prevalence from 14% to 9% in a mere three years with snus and vaping, South Korea having double digit declines in cigarette sales as non-combustion alternatives became available. We are seeing a proliferation of vape shops and other ways to access alternatives to cigarettes in Europe, the US, Canada and elsewhere, and cigarette smoking falls as this happens. This should be as surprising as hearing icebox sales fell as refrigeration became widely available, or horse purchases declined as automobiles did. One need only be mildly curious to walk into vape shops to see who the customers are and need only live a non-cloistered life to meet people who have switched from smoking to massively less hazardous alternatives.

Yet all this is happening in an environment where smokers are still hugely misinformed about relative risks, legislation protects cigarettes, and there is a lack of incentives to switch to low risk products. If policy could align with health goals we could see a repetition of other huge public health breakthroughs. Such as the move to sanitary food, or science-based pharmaceuticals, or to massively less hazardous automobiles, airplanes, industrial machinery, etc.

There is a continuing failure of vision; of the ability to act now to prevent those 20,000 deaths a day. The fact that we have the tools to do so, and to do it quickly, should encourage us to overcome resistance to rational policies on nicotine. Abstinence-only policies have a very poor record of success. Pragmatism works.

David Sweanor: I see tremendous drive, commitment and creativity among those involved. They know they are at a huge disadvantage in terms of resources, but that has never discouraged advocates.

I think the positions taken by some of my former colleagues at WHO and some other health institutions are not just bad in terms of perpetuating smoking, but bad for public health in general. Public health has the power of persuasion far more than the power of coercion. We require public trust to effectively do our work. When seemingly credible bodies act against basic public health principles and established public health ethics they ultimately hurt the overall credibility of the field, not just the credibility on issues of nicotine.

When we fight for the rights of consumers; for the right to be empowered rather than merely punished and the importance of science and rationality over ideology, we are involved in a longstanding public health exercise. We have seen it on AIDS, birth control, alcohol, illicit drugs, automobiles, active transportation and a myriad of other issues. If major health bodies wish to maintain public respect in an age of speed-of-light information accessibility, they must start working with the public rather than imposing ideological agendas on them. Nicotine harm reduction advocates are driving home that message, but it is a shame some health organizations have already forgotten the lessons from AIDS and other campaigns.

David Sweanor: I was asked by AG Tom Miller, a person I greatly respect, if I would be willing to give advice to JUUL. Given the 20,000 daily deaths globally from cigarette smoking and that JUUL is a product that is a significant threat to the cigarette business, of course I said yes. Like all my work on this issue, it is pro bono.

Some background might help. Since I first got involved in efforts to reduce smoking I have put great effort into trying to understand industry dynamics. This has involved reading financial reports and securities filings as well as taking in the investor presentations by these companies and buying single shares in tobacco companies. I am also on the distribution lists of, and in regular contact with, many of the world’s leading analysts of tobacco stocks.

But learning about the industry goes much deeper than that. I have sought out meetings with current and former industry executives and others with insights. This includes those who have left the industry due to issues on conscience, those fired, those retired and many who still work there. Like a good historian, or investigator, I triangulate; seeking to get as many views as possible and to test the veracity of what I learn. This has proven invaluable in my policy and litigation work, but also in simply understanding the environment in which we work. Many in tobacco control claim we are in a ‘war’ but then avoid acquiring any of the intelligence necessary to effectively win one.

In fact, back before the days of Internet and facial recognition, I had many meetings with industry execs who did not know who I was. I was amazed how much I could learn. Never turning down an opportunity for a friendly chat over drinks was also an extraordinarily good source of insights. When I started working with ex-CIA people on an investigation of industry malfeasance it was fun to compare notes on our intelligence gathering techniques!

The cigarette industry has lived in fear of disruptive technology for a great many years. Such products have the potential to devastate their business in short order, by giving consumers better options, by giving regulators more tools to decrease smoking and by empowering an onslaught of new tort actions for those still promoting lethal cigarettes. JUUL is currently seen by financial markets as one of the biggest threats to the cigarette business.

If alternative nicotine companies can survive the minefield of Big Tobacco skullduggery, overzealous regulation that protects cigarettes, and misinformation campaigns and scare-mongering by abstinence-only aficionados, cigarettes could rapidly be consigned to the ashtray of history.

If the company that has emerged as one of the most powerful threats to the wellbeing of the cigarette trade asks for advice, I sure won’t say no. Whether they take it, time will tell.

David Sweanor: We have seen this story before. With anything that has the potential to end the cigarette industry’s ultra-lucrative ‘nicotine maintenance monopoly’ (a term Ken Warner, John Slade and I used in a column in JAMA in 1997) there is strong opposition. Not so much from the cigarette companies, which would face liability risks for killing less hazardous alternative products, but from regulators and some anti-tobacco groups pushing an abstinence-only agenda. Think of how snus was banned in many countries, NRT was very heavily regulated to the point of being largely non-viable as an alternative to cigarettes, Star Scientific was hounded out of existence, etc.

Of course the ‘teen brain’ scare is based on very weak studies of rodents, and if it is a problem at all we know it is not a big one since hundreds of millions of people starting smoking as teens and brain damage is only detectable among some of those who went into politics, and that is possibly merely correlational.

But on other issues the science is clear. A tremendous number of those teens are losing parents, grandparents, teachers, coaches and others who are important in their lives due to deaths from smoking. Most of those they are losing wanted to stop smoking. Vaping saves lives.

The attacks on nicotine miss what should be the main issue: the ability to end an epidemic claiming 20,000 deaths a day. The attacks focus on what are usually hypothetical, minor, containable problems and seek to shape the debate around risks rather than benefits. It would be like campaigning against smallpox eradication because of the potential of some unintended consequences. These efforts to misdirect the debate magnify small risks while ignoring mindbogglingly huge potential gains for humanity. We need to see the big picture, not re-enact the Monty Python ‘Holy Grail’ scene where the king gestures out the window saying ‘Son, someday all of this will be yours!!’ and the son says ‘The curtains?’

We need visionaries. People who see that we can accomplish one of the greatest public health improvements in the history of mankind. In our early days I think tobacco control had visionaries. Many became my personal friends. We can get there again.

David Sweanor: I do indeed see the emergence of a new generation of advocates. Just as the leaders of the past often emerged from unsuspected places (Gar Mahood was a salesman, not an oncologist), I see the same drive now from many in the vaping community. Their meetings are like non-smokers’ rights meetings were 40 years ago – people standing up, standing together, and enthusiastic about changing the world.

I think tobacco control has become too risk-averse and too ‘fundamentalist’. Many younger people at tobacco control conferences tell me they feel like they are at a religious revivalist meeting. I know what they mean. The energy and drive and willingness to challenge assumptions and try new ideas is nothing like it was when we were young, and nothing like the energy we see now at harm reduction meetings.

New public health leaders are emerging. Some of those from my cohort see how valuable that is. Others from my cohort will likely find that history eventually sees them as having gone on too long with too few new ideas and falling into comfortable careers and ideologies. Unless they adapt, historians will ensure that the flaws in their reasoning (and their research) will be on full display for their grandchildren. And it will be embarrassing.

David Sweanor: My 2010 French-made Look road bike passed 109,000 km on yesterday’s ride.