Hope for the Future: E-Cigarette interview with tobacco expert Scott Ballin
Tobacco and public health expert Scott Ballin is questioned by researcher Paul Bergen in an interview that sheds light on evolving attitudes towards harm reduction and e-cigarettes - and offers hope for the future.
<p>SCOTT D. BALLIN is a tobacco and health policy consultant in Washington, DC and has spent more than 30 years involved in issues related to tobacco and health. He was the VP for Public Policy and Legislative Counsel at the American Heart Association and Chairman of the Coalition on Smoking OR Health (ASC, ALA, AHA). More recently, he served on the Steering Committee of the Alliance for Health Economic and Agriculture Development (AHEAD), an informal organisation committed to bringing parties together in order to discuss controversial issues, remove barriers, foster constructive dialogue and look for new opportunities to find common ground. He continues to advocate for 'dialogue' and is currently serving as an advisor to the Institute for Environmental Negotiation at the University of Virginia in putting together a series of dialogues on harm reduction.</p>
PB: You appear to be one of the few people who seem to be relatively unaligned when it comes to tobacco and nicotine issues. Would it be fair to characterise your goals as 1. trying to get all stakeholders to sit down together and 2. developing a language that all stakeholders can use?
SB: While I am 'unaligned' , I passionately retain my public health focus and goals. That has not changed. What has changed is the environment.
With FDA oversight we entered a 'new era' that was not just focused on 'tobacco' but encompassed debates and discussions on nicotine and other new alternative products. As far as trying to get people to sit down.... absolutely. I have found that when people, no matter how much they dislike and distrust each other, can sit in a room that is a 'safe haven ' and facilitated to ensure civility, there can be progress made. No one has to give anything up and surprisingly there are areas where, through the dialogue, a path forward can be found.
Interesting that you should also ask about a 'language' that all stakeholders can use. I am in the process of writing a piece that suggests that we need to take a careful look at how we define and use words and terms in the tobacco, nicotine, and alternative products environment. We seem to be using terms that are based in the 1980's and 90's and not in the 21st century. That needs to change.
PB: Just like an actual war, do you think that in the case of the tobacco wars, where there seems to be little justification for current policy positions (and I mean that in a general sense to include the orientations of NGOs), that there is a desire for an honourable exit?
SB I think there can be an honourable exit for all of the stakeholders and interests looking for one. But it will take some work and the willingness to let go of the past and accept the future. For those who wish to stay in, maybe we shouldn't call it an exit, but rather a reorientation toward a changing environment. For those willing to look at the reality of the situation they in fact can become the leaders for the future which is the far more commendable avenue to take. I include all of the various stakeholders in that view. Stakeholders who wish to hold on to the past will be the forgotten ones when we look back ten to fifteen years from now. They can exit gracefully as the environment continues to change, but I know that some will go kicking and screaming unfortunately.
PB: Given that the FDA Centre for Tobacco Products has not exactly been objectively pursuing risk reduced nicotine are you still optimistic about it being the most likely vehicle for improving the nicotine use landscape in the next few years?
SB: I am cautiously optimistic about what the CTP will be doing in the coming months and years. They were given a huge task and so many statutory mandates to accomplish by Congress that it is surprising that they have been able to begin to move at all on the issue of harm reduction - one of the areas that I believe to be most important to the future of public health.
I know they are now beginning to look at the issue of modified risk tobacco products (workshop scheduled for August) and I am pleased to learn that they are planning to involve numerous stakeholders in that dialogue.
One of the other challenges they will have is dealing with a statute that was outdated even before President Obama signed the legislation into law. I think it is becoming increasingly clear, that one can't deal with tobacco in isolation. We need a more coherent tobacco, nicotine and alternatives products regulatory framework that regulates all these products based on risks, relative risks and intended use.
PB: Though tobacco control and abstention have little difficulty in obtaining international representation why do you think that local acceptance or instances of successful risk reduction environments do not travel well?
SB: I look back on my own experiences with the tobacco issue when it was necessary to have a 'bad guy'----an enemy.
It helped us in the US to develop a menu of policy goals that included the traditional tobacco control arsenal of taxation, clean indoor air, advertising restrictions, sales and distribution restrictions, labelling reforms, and the need for regulation (FDA). To get those important policy changes front and center the focus had to be on demonising the enemy.... and rightly so.
We still adhere to those objectives in the US but the reality is that once you get into the area of product regulation and there is an agency charged with regulating tobacco (and nicotine), the way you approach the issue changes. You can't merely continue to throw grenades over the wall hoping you're going to bring down the 'enemy'. You have to meet the enemy face to face and talk about how they are going to change their products and business practices. Many people are reluctant to go face to face with them. On top of that there are other players who don't come out of Big Tobacco. pharmaceutical companies, e-cigarette manufactures, biotech companies and others helping change the debate and dialogue and forcing change on the traditional tobacco companies through competition.
As far as risk reduction being accepted in other international environments, I think that will take time. The US ( and Europe) is in a very different place and I personally accept and support the fact that each country has to deal with the climate and situation they are facing at any given moment. Without an effective regulatory structure in place there will remain a deep distrust about industry's motives and goals. Harm reduction for some is nothing but an industry ploy to sell more products under the guise of being responsible. I am hoping however, that what we can do in the US in establishing a more effective and rational regulatory structure for all tobacco, nicotine and alternative products, will serve as a model that will one day be adopted by others.
PB: Given the almost unfathomable amount of money at stake, and the American tradition of free market capitalism, is there any real hope for prioritising risk reduction over business interests?
SB: I believe that risk reduction and business interests can and do share common goals and objectives. I think this was recognized by the Institute of Medicine in its landmark report Clearing the Smoke that had as one of its major recommendations the need to give manufacturers (tobacco or pharmaceutical) incentives to develop and market science based lower risk regulated products. I have often said that I believe that Incentives + Innovation + Competition + Effective Regulation = a win/ win for business and public health. One of the dilemmas that we face however, is that traditional tobacco control advocates in the US and elsewhere remain more focused on fighting the 'tobacco wars' than in finding a path forward by and through which we can advance public health goals.
PB: Would you say that because electronic cigarettes have made low-risk recreational nicotine use a reality (and without the persistent misinformation attending smokeless tobacco) that finally switching might actually compete with abstention in regards to official policy? Or will the threat to longstanding positions just further entrench those positions?
SB: This raises one of the questions that I have been trying to get a handle on. Abstinence from what? Smoking (cigarettes)? Tobacco (all use of tobacco)? Nicotine (all use of nicotine?) In many regards the e-cigarette or other low-risk nicotine containing products offer the same solution that the NRT products currently do, and that is why some of the pharmaceutical companies are working diligently to keep these products off the market. If it is not the nicotine that is the primary health problem ( and it is not) then we need to be clear on what kinds of products we as a nation are going to accept or not accept.
Clearly science-based regulated alternatives to combustible cigarettes should be allowed into the market place. To do it however, we need a more coherent regulatory policy that the will regulate all of the various products based on their risks, relative risks and intended uses. As a democratic society in which capitalism is encouraged we also need to recognise that abstinence and prohibition (while commendable) are probably not the public health answer.
PB: If you were to predict what the regulatory landscape might resemble a decade from now?
SB: I am hoping that after a decade of neglect we'll find a more workable, rational and coherent regulatory system in place. Ideally it would be a regulatory structure that brings all tobacco, nicotine and alternative products under a single umbrella and sets regulations not based on who makes the products but rather on the risks, relative risks and intended uses of the product. This would mean making the Center for Tobacco Products at the FDA, the Center for Tobacco, Nicotine and Alternative Products.
If the agency does its job effectively and bases its actions on science, transparency and inclusiveness, then the rhetoric and public relations activities that currently dominate tobacco control will slowly dissipate. As part of this effort, manufacturers should be given incentives to develop new science based low risk products. All of this would hopefully drive the most dangerous products out of the market place and replace them with products that are somewhere in the area of 95 % lower in risk than what is currently on the market. This might not satisfy some in tobacco control but it would be a tremendous victory for public health
Many thanks to Dr Scott Ballin for making the time available for this interview.