In the latest in our series of interview with experts on electronic cigarettes and/or tobacco harm reduction, Paul Bergen interviews Clive Bates, former director of Action on Smoking and Health.
Clive Bates has had a varied career in the private, public and not-profit sectors. He was the Director of London-based campaigning organisation Action on Smoking and Health from 1997 to 2003. He no longer works professionally in the public health field and specialises in energy and the environment. He has no conflicting interests or affiliations in health organisations, pharmaceutical companies or the tobacco industry, but continues to take a personal interest in public health policy. In this interview, he is speaking strictly in a personal capacity and not for his employers past or present.
Paul: In tobacco-related circles you are perhaps best known for a 2003 document you were first author on while with ASH-UK, European Union Policy on Smokeless Tobacco, which essentially argued for modifying the ban on smokeless tobacco so as to provide a safer nicotine source than cigarettes for smokers. Now, ten years later, ASH seems to teeter between arguing for or against safer alternatives whether snus or e-cigarettes. At the time you were with ASH did you have support within the organization when you were developing that paper or were they just putting up with you?
Clive: The idea of ‘harm reduction’ is always controversial – whether it is needle exchanges for intravenous drug users, contraception for teenagers, or even cycle helmets. There are people who think that promoting anything other than quitting smoking completely is somehow an unacceptable compromise. But this takes no account of real human behaviour and that fact that what matters is what people actually do, not what you want them to do.
There was support within the organization because we argued the case properly and used the best evidence we had at the time, and it is even clearer now. You’ll notice that document is co-authored with some of the leading academics in this field and so the case has both weight of evidence and some authority. There were doubtless some in and around the public health field who were uncomfortable. But then, as now, they just could never make a convincing argument, so they had to put up with me and the others like me who see this issue more pragmatically. ASH remains pretty reasonable on all this if you listen carefully to what they say. The problem lies with the big health charities and European alliances, which just seem to take positions that appeal to their instincts and what they think will be popular.
Paul: There have been a few examples of people who started as active in anti-smoking or clean air initiatives but ended up promoting alternatives for smokers (for instance Michael Siegel, Bill Godshall or David Sweanor) but yours is the only case I know of where an active support of harm reduction originated from within an anti-smoking organization. When you started with ASH, were you already inclined toward harm reduction or did that position evolve over time?
Clive: I was fortunate enough to be the Director of ASH, and it is easier to influence the position of an organization if you are in charge! My views definitely evolved as I came to understand the underlying science better.
My first foray into this arena was looking into ‘low tar’ cigarettes, and whether they really were reducing health risks (nb. The answer is definitely ‘no’). That Low Tar report is still available and mixes science and some of the most tobacco industry documents to paint a picture of companies deliberately and cynically engineering false reassurance in response to the health concerns that were rising at the time. But the interesting underlying scientific premise is that smokers smoke to meet their nicotine needs (so-called nicotine titration) and adjust their behaviour to compensate for, say, vent holes in the filter, in a way that the official cigarette tar and nicotine testing machines do not.
I campaigned to have the tar and nicotine numbers removed from packs in the 2001 tobacco directive because they sent a misleading signal, but alas to no avail. The directive did at least clamp down on branding words like ‘mild’ and ‘low’ (article 7). But once you understand nicotine-seeking as the prime driver of smoking behaviour and that is the tar particles and hot gases in the smoke that are the main causes of disease, you are soon drawn into harm reduction and the idea of clean or cleaner ways of nicotine delivery. I had brilliant teachers on all of this in Martin Jarvis and Ann McNeill. They were part of a London-based group of scientists inspired by the work of the late, great Mike Russell, who pioneered the early understanding of the pharmacology and psychology of nicotine dependence.
Paul: Though one would think that for any group working with tobacco and health that promoting safer alternatives (such as snus or e-cigarettes) should be a logical step this just does not seem to happen. Is there something about the culture of these organizations that make change from within difficult?
I’m incredibly frustrated by some of the health groups. They’ve taken a cavalier attitude to the evidence and ethics of harm reduction, and seem to show no empathy or concern for the people they are supposedly trying to help. It is as if they value their anti-tobacco industry credentials more than doing something about cancer, lung and heart disease. If you swear a fight to the death with Big Tobacco, you will be treated kindly by politicians, the media, funders and the public. But if you care about health, and I mean really care, there are some tougher choices and trade-offs to make about reducing the harm caused by tobacco.
I also think there are some uneasy conflicts too: the European Commission provides funding to some of the Brussels based health lobbyists; Big Pharma is involved to some extent and has mixed motives; and some of the health charities have a funding and research philosophy that is ideological and narrow-minded rather than a genuine scientific quest. There is certainly a lot of group think and lack of internal critical challenge within these groups. Sad to say, I don’t think they even recognize that as a weakness.
Paul: In your most recent writing on tobacco, I see that you reiterate much of what you said ten years ago with the benefit of the evidence of the time since, but you restrict your comments to snus as an alternative. What are your feelings about e-cigarettes as alternatives and in comparison to snus.
Clive: I think the same arguments apply to e-cigarettes, vapour devices, NRT, non-combustible tobacco. They are all vastly less hazardous as a way of consuming nicotine and, unlike smoking, have negligible risks or risks that are not out of line with other lifestyle risks we routinely accept. Which do I prefer? Whichever works for each smoker.
My concern is not whether these alternatives are dangerous - they aren’t. My concern is whether they can quickly gain market share from cigarettes. The challenge from a health point of view is to get as many smokers, especially those over 40 years old and looking like they may be smoking for life, to switch. So I think we need a broad range of alternatives available to suit individual tastes and motivations.
This is an area where market forces could drive strong pro-health innovation as makers of these products seek to win market share from smoking. There will be an instinct to regulate, and in doing so to be excessively restrictive – but we must be so careful. Too much caution or excessive regulation of these alternatives would throttle the market and would in effect amount to protective regulation for the cigarette market. So my message to those health interests who want very strict regulation of new nicotine products is: “beware what you wish for, because if you get what you want, you will be doing the dirty work of the cigarette vendors for them”.
Paul: In the last decade we have seen a strong popular acceptance of e-cigarettes combined with fairly positive media coverage along with the growth of a healthy and competitive e-cigarette industry along with responsible oversight agencies such as ECITA. Both tobacco and pharmaceutical companies have invested heavily in developing and promoting safer alternatives (inhalers and various smokeless variations). In your older writing you supported greater regulation of nicotine alternatives – would you still take that position or do you think that recent developments have provided a good enough solution?
Clive: Actually, I favoured regulation because I thought it was a choice between these products being regulated or being banned, and that some sort of regulatory framework would be needed to win support from legislators and broader public acceptability. I still think that may be the case, and there will be some sort of move to regulate these products. The question is what sort of regulation? One of the papers I am most proud of was written jointly with Ann McNeill and Jonathan Foulds and was a robust attack on the excessive regulation of NRT at the time [abstract, full text].
The basic flaw was that the regulators were assuming that users of NRT would otherwise be abstinent, whereas in the real world they would be more likely to continue smoking. So, for example, it was absurd to warn pregnant women not to use NRT products, because they would only be using it to stop smoking. Once you see the comparator as smoking rather than not using nicotine at all, the purpose of regulation looks very different. So I would look for regulation that increases uptake of alternatives by building confidence in the products.
Good regulation could include:
- safety (it doesn’t burn or blind the user)
- efficacy (it does deliver a satisfying dose of nicotine)
- health claims (the maker can legitimately say it is much safer than smoking)
- marketing (it can be promoted as an alternative to smoking)
- branding (it can be made attractive to smokers)
- approved medical advice (doctors recommend it for die-hard older smokers)
- tax (advantageous tax treatment relative to cigarettes)
- availability (it can be sold anywhere cigarettes are sold).
Paul: It seems as though in the last few years snus has also fared slightly better in press coverage. However despite the indisputable evidence that these alternatives are indeed safer than smoking, we seem to have more extremist rhetoric from the anti-smoking agencies and an even more prohibitionist attitude from most health and political (FCTC, WHO) groups – is there any hope that safer nicotine alternatives will persist and perhaps one day dominate?
Clive: It is hugely frustrating to see so many people whose job is supposedly to protect health going to work and doing exactly the opposite. Prohibitionist rhetoric and practice has never served society well in practice. The WHO Tobacco Free Initiative continues to disappoint and ignore the real-world needs of smokers. Its own advisory committee actually has quite sensible things to say on all this, but these have been ignored or quoted highly selectively in recent WHO papers - see FCTC COP5 papers 12 & 13.
However, I am still optimistic. The truth is the truth, and it will out. Social media make a powerful vector for the truth, challenging the handed-down wisdom of these authorities whilst sharing knowledge and building confidence of smokers below the radar of most health professionals. There are some great centres of unbiased advice now – I particularly like Brad Rodu’s Tobacco Truth, Mike Siegal’s Rest of the story, Carl Phillip's E-Pology and Anti-THR Lies blog, and some of the forums. These are now creating a kind of pro-health insurgency against the dumb harmful orthodoxy of the big health interests.
Paul: Did working in Sudan alter your perspective on tobacco control in respect to populations where smoking is really the least of their worries? Isn't it curious that when we are faced with global warming, overpopulation, environmental degradation, that nicotine use continues to capture so much public and political attention?
Clive: Work in Sudan was quite an experience, and there are certainly many problems to face. The other problems mentioned are truly huge, but in terms of global premature death toll, including in developing countries, tobacco is still a world class killer. In some ways, smoking is even worse for those enduring extreme poverty because it compromises their ability to work and to support themselves, and eats into their already inadequate income. Given the harm caused, I don’t think too much political attention is paid to nicotine. In fact, I wish nicotine would attract more political attention, but by that I mean more critical attention to the science of risk and to the ethics of harm reduction. There is no reason why we shouldn’t do more to tackle the burden of disease caused by smoking while taking on the challenges of climate change, food security, poverty and so on. They are not alternatives. Unlike these other great problems, there are some straightforward solutions for smokers: quit if you can; if you can’t quit or don’t want to, switch to a much less risky way of taking nicotine; if you don’t want to do that, you do at least know that viable alternatives are there for you and you are responsible for your choice. Take away the alternatives, and you just have a ‘quit or die’ proposition to dealing with nicotine addiction.
Paul: I see that your blog is back up and running after being inactive for a few years. Can we expect regular commentary on tobacco again?
Clive: I’m not sure – it depends what I do next in my career. I love blogging but my head is mostly filled with thoughts about environment, energy and climate change these days and it’s hard to stay on top of developments in the tobacco field. I put together a blog article on snus out of despair when I heard where things were heading with the new EU tobacco products directive. Many of the health groups in Europe have just been following the line of least resistance with no justification or evidence to support the positions they have taken (you can read my challenge to them in the comments). Even though I don’t work in that field, I have at least taken the trouble to set out a case based on evidence and argument. These issues should be their main concern, yet they have not set out a reasoned argument for what they are pushing for. A Swedish Member of the European Parliament, Christian Engström, has had enough and has written a very good open letter to the anti-snus lobby inviting them to make their case. Let’s see if they do.
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