Electronic Cigarette Summit 6
I still can’t believe that we’ve reached the 6th E-Cig Summit – it doesn’t seem so long ago that the first one was held! This is very much a non-commercial conference, with sales pitches banned (hooray!) and proficient speakers who are good at lightening up some challenging topics with a bit of humour. Add that to superb organisation and it all makes for a great conference.
I’d recommend everyone who is interested in vaping to the summits, but not everyone has the time or the funds. So once again, for those of you who are interested I’ve popped my notes on to the blog.
I do hope you find them useful, but please bear in mind that they are written from a combination of notes and memory, typed up after a few glasses of wine at the end of the summit and completed in the early hours of the morning. As a result there are bound to be some errors, all of which are my own, so apologies in advance to the speakers for any mis-reporting.
- Why do countries have different policies?
- E-Cigarettes in Low Income Countries
- Why a comprehensive tobacco control policy is essential
- Tobacco harm reduction in the real world
- Considerations for regulating e-cigarettes
- Panel Discussion #1
- Unanswered questions in tobacco control
- Does e-cigarette cause subsequent smoking in adolescents?
- Should health professionals recommend the use of e-cigarettes
- Do e-cigarettes help smokers quit?
- The balance of the public health impact of e-cigarettes
- Panel Discussion #2
- Market Impact of Regulation
- Vaping in an Unregulated Market
- Understanding Disruption
- Vaping products regulated as medicines
- A risk proportionate approach to e-cigarettes
- Panel Discussion #3
- Public health professionals still have concerns
- Salford Swap to Stop Pilot
- Halting the intergenerational reproduction of smoking
- Perceptions and misperceptions
Electronic Cigarettes and History: Why do countries have different policies?
Professor Virginia Berridge, London School of Hygiene and Tropical Medicine
For the first time we had a bit of history at the summit, Professor Virginia Berridge kicked off with the conference by looking at what historical factors have lead to radically different policies on vape in two different countries; the UK and Australia.
For reference, while the UK has one of the most liberal approaches to vaping and tobacco harm reduction, Australia has effectively banned vaping with nicotine considered a poison. (An exception is made for nicotine in tobacco – provided it is used in the most harmful way possible i.e. for smoking.)
The origins of the liberal approach in the UK goes back several decades, when harm reduction had its origins in the approach to both HIV and smoking. In particular, Michael Russell, a legend amongst the Tobacco Harm Reduction (THR) community pioneered a harm reduction approach that eventually gained wide acceptance in the UK. This, along with the traditional provision of services to help people quit smoking, often with THR products, lead the groundwork to a greater acceptance of vaping.
In contrast, Australia had far less experience with THR and a leaning towards cold turkey quitting methods.
Virginia also touched on other factors in the UK. This included activism, although I was a little disappointed that she only mentioned Action on Smoking and Health, which was no friend of vaping in the early days, and indeed at one point supported the medicalisation which would have meant an effective ban on devices in the UK. (Many years later, we are yet to see a medical device on the market.) She didn’t mention the small group of vapers who dedicated much of their time and energy to promoting the benefits of vaping. Still, the contrast is Australia, where there are [still] a number of organisations and personalities completely opposed to THR.
There was also a stroke of luck with Public Health England, which was a new organisation which did not carry the baggage of existing preconceptions and was more open to a new stance on nicotine.
What does all this tell us? For a start, while scientific evidence is important, it doesn’t by itself determine outcomes. After all, both the UK and Australia have access to the same evidence. Instead evidence – and ethical principles- is filtered through key personalities, preconceived ideas, state structures and more, all of which have their origins in pre-history.
E-Cigarettes in Low Income Countries
Judith Watt, International Tobacco Control Consultant
Low income countries have higher rates of smoking, so why haven’t they embraced vaping?
Regulation is complex, and Judith outlined seven different areas of regulation. Low income countries, according to Judith, have a reduced capacity for implementing these regulations, and do not want to divert resources away from other projects.
What’s more, quite often the problems smoking cause are not as visible as they are in other countries. For a start, the population is much younger – in Niger, for example, 50% of the population is under the age of 15, compared to just 18% in the UK. So the impact of smoking is not as visible at is in the West.
That leads to situation like Indonesia, which has implemented a 60% tax on vaping. [Not mentioned in the presentation were comments from Indonesian ministers that they wanted to protect tobacco farming and convert vapers to smokers. In Indonesia, too, the country has traditionally struggled to collect tax in traditional means and is heavily dependent on tobacco taxes.]
Meanwhile, tobacco companies are not staying still. Whilst Philip Morris International says it supports restrictions on marketing, it has been continuing to market heavily in Indonesia. (The last time I was there, I also noticed a slogan used by one of the other companies – Never Quit!) Slides were shown of tobacco marketing, and of Philip Morris discussing the success of the new tobacco brands. The result, Judith believes, is a tragedy, with sky high smoking rates in both the old and amongst under 18s.
— ECigaretteDirect (@ECigDirect_UK) 15 November 2018
Why a comprehensive tobacco control policy is essential to underpin a sensible harm reduction strategy
Deborah Arnott: Action on Smoking and Health
In Deborah’s presentation she argued that smoking is going down faster in the UK because of a comprehensive tobacco control strategy. Effective harm reduction, she believes, lies in encouraging smokers to switch completely to e-cigs (and not dual use) and needs smokers to be motivated to quit smoking.
The success rates are certainly outstanding. In 2006, i.e. just before vaping hit the UK, smoking rates were at 33%. Now they’re at 17%. In contrast, EU smoking rates have fallen from 32% to 26%.
— ECigaretteDirect (@ECigDirect_UK) 15 November 2018
Deborah went on to highlight where the UK goes further than the EU in motivating quitting, [using measures such as reducing affordability, mass media campaigns and smoke free laws, amongst others. There’s also a difference in how vaping is treated, the most important being a difference in attitude.
Another key difference is a huge number of quit attempts, with 46.3% of UK smokers attempting to stop smoking in 2016. This was the highest of the countries compared, which varied from the Netherlands at 31.5% to Hungary at just 10.4%. E-cigs are the most likely tool for a quit attempt in the UK, at just over 50%, compared to just 5% in Spain. Deborah argues that the EU Tobacco Products Directive has not reduced e-cig use. Deborah didn’t cover the effect of limiting nicotine strength to 2%, which some in the industry feel could limit take up of vaping.
We’ve also finally seen a small improvement in the perception of vaping after recent falls. In 2013 61% of the public thought vaping was either a lot safer than smoking or completely harmless. That declined to a low of 49% in 2017 before a small improvement in 2018 to 55%. Perhaps that’s partly due to doctors – few discuss vaping with their patients, and when they do only 34% recommend e-cigs, with 21% advising smokers not to switch to vaping.
Deborah’s conclusion was that we need more tobacco control, including mass media campaigns, more taxes and attempts to address the public’s confusion around vaping.
— ECigaretteDirect (@ECigDirect_UK) 15 November 2018
The long-time Scandinavian experience with Snus – tobacco harm reduction in the real world
Karl E Lund: Norwegian Institute of Public Health
The next talk was a particularly interesting follow on, as it highlighted both a massive public health failure and the dangers of lying to the public about the relative risks of tobacco products.
Let’s step back to 1986. Passive smoking was on everyone’s mind, and smokers were having to go outside to smoke. This might be a pain in the UK, but in a Norwegian winter the inconvenience goes to a whole other level! This lead to two options – acquire a survival kit or switch to Snus.
But as Snus grew in popularity tobacco control grew alarmed. Fears included:
- toxic substances
- new epidemic
- a gateway to smoking
- dual use
- delayed smoking cessation
- heart conditions
Of course, they didn’t know any of these were a concern, so tobacco control came up with the “caring lie”. They would tell smokers these fears were real, and if it turned out to be true, they would have protected (smokers?) from these dangers.
So what happened?
First, fortunately, smokers ignored public health and switched to Snus anyway. The results?
- Snus displaced cigarettes
- there was no increase in tobacco consumption
- there was no evidence of a gateway effect
- fewer people started smokingv
- more people quit smoking
- Snus users didn’t get smoking diseases
It’s now estimated that Snus carries just 5% of the risk of smoking. Smoking rates are incredibly low (in Sweden, which has been using Snus for longer, it’s just 7%). And lung cancer? The rate of lung cancer in Europe is 220 per 100,000 – in Sweden it’s just 87. And low rates of disease carry over into other cancers and diseases. In fact, the death rate for all causes in Sweden per 100,000 is more than half that of the rest of Europe. (That’s per year – unfortunately, everyone still dies eventually, despite PH’s best efforts.)
So what has been the reaction of the government?
Finally, Karl finished off with a great quote which I am sure will be ignored by many anti-nicotine campaigners:
“It is difficult for us in tobacco control to realize and accept that snus and e-cigarettes may have greater potential to make smoking obsolete than the regulations we have spent a lifetime fighting for.”
The Canadian Experience: Considerations for regulating e-cigarettes
James Van Loon, Director General, Tobacco Control Directorate, Health Canada
James Loon of the tobacco control directorate in Health Canada is on a mission to get smoking rates below 5% by 2035.
(A bit of background; Health Canada was at one time very much against vaping and often confiscated vapes at the border. In fact, back in 2010 they told me that even zero nicotine devices could not be sold.)
Health Canada has implement the usual tobacco control measures including indoor bans, taxes, graphic warnings and so on, which James believes is the cause of falling smoking rates. They’re keen on vaping if it can bring a public health benefit, but are still worried about the gateway effect.
Their solution is to ban anything that could appeal to youth. This includes lifestyle advertising, flavours that could appeal to children, and promotion of products with attributes that could appeal to youth.
On the other side, Health Canada has leapfrogged the UK in developing statements that the industry can use to inform smokers that vaping is safer than smoking, e,g. “If you are a smoker, switching completely to vaping is a much less harmful option.” Seeing vaping as both an opportunity and a threat, they plan to continue monitoring e-cigs (and, presumably, stripping all the fun and flavour from brands, too.)
I’m not aiming to cover the panel discussion, but I just wanted to mention a point Clives Bates raised: That it would be better if tobacco control got out of the way of vaping all together.
Unanswered questions in tobacco control – science is never about knowing everything
Professor Konstantinos Farsalinos, University of Patras, Greece
Science, Konstantinos believes, should be about tackling those problems and questions that need to be addressed. Those answers create new problems and questions leading to an ongoing cycle.
But what happens when you look for problems? More specifically, what happens when a scientist is paid to look for problems? They find them. Even if they’re not there.
That’s exactly what is happening with vaping. Money is provided not to solve problems but to find problems. An example is the gateway effect. There is a lot of research to prove there is a gateway from e-cigs to smoking, but little research into e-cigs being a gateway FROM smoking.
This is part of a predisposition to a prejudice against vaping. After all, vaping looks like smoking, it is used like smoking, so it must be bad. And any negative link is treated as causation, not correlation.
To demonstrate this prejudice, Farsalinos used the example of a study that found a link between vaping and myocardial infarction. Farsalinos used the same methodology to find a link between anti-cholesterol medicine and heart diseases. Clearly this does not exist, just as there is no link between vaping and myocardial infarction.
Farsalinos argued that we need to give people accurate information on the risks of different products. Tobacco control are worried that people think vaping is safer, but this is true and it’s not ethical to create misperceptions. People need accurate information to make decisions about their health. The proper information to give them is the current knowledge on risks. We can also learn from medicinal products, where known risks are balanced against the greater benefits of a medicine.
Disentangling the gateway hypothesis: does e-cigarette cause subsequent smoking in adolescents?
Dr Lion Shabab, University College London
There’s a number of problems with assessing the gateway theory (that e-cigs could lead to smoking). For example, in literature, only observational data is available, as it would be unethical to do a randomised trial. So Dr Shabab attempted to assess the hypothesis using three separate techniques: Face technique (i.e. descriptive analysis), advanced analytic techniques and forecasting techniques using computer modelling.
Given the speed and technical nature of the talk, I’m going to duck out of the details here and go straight to the conclusions. These are:
- The impact of vaping on adolescent smoking rates is either zero or negligible.
- Vaping may have a protective effect on children who might have otherwise smoked.
- While we need to continue to monitor data and cross-validate the results, at present the best evidence available suggests we don’t need to worry about a gateway effect.
— ECigaretteDirect (@ECigDirect_UK) 15 November 2018
When and how should health professionals recommend the use of e-cigarettes
Professor West, UCL
Robert looked at three recommendations we could make to smokers. These are:
- We don’t know how harmful e-cigs are, or if they can help you to stop smoking, and so we can’t recommend them.
- E-cigarettes are almost certainly far less harmful than smoking but we do not have strong evidence on how effective they are. So we can only recommend them if there is no other way of stopping for you.
- E-cigarettes are almost certainly far less harmful than smoking. They are popular and many smokers appear to be able to switch to them without difficulty. Have a go at switching straight away – if it doesn’t work you can try something else later. If you can switch then you should consider quitting e-cigarette use later.
Well, every day of smoking (after a certain age) costs 4-5 hours of life. That means quitting now is urgent. We know that e-cigs deliver a tiny fraction of the toxins in cigarettes, apart from nicotine which is low risk.
There may be long-term harmful effects but these will be far less than that of smoking. Not only does English data shows that using e-cigs doubles the chance of you being successful, it also almost doubles your chance of staying smoke free after you have quit.
How much of a difference can e-cigs make? English data shows if smokers followed recommendation 1, an extra 50,000 people per year would continue smoking.
Do e-cigarettes help smokers quit?
Peter Hajek, University of London
The problem with assessing quit rates with e-cigarettes is that there have only been 2 randomised control trials. A Cochrane review has concluded that e-cigarettes are better than a placebo, but the data is not good enough to be confident about the size of this effect.
Peter went on to give examples of a number of poor studies, or at least studies that are being poorly interpreted. For example, one study offered medicine and e-cigarettes to smokers. (It appears that these were offered together.) It also offered cash to some smokers if they successfully quit. The study wasn’t trying to test the effectiveness of e-cigs or medicine, it was testing how well smokers reacted to different offers.
The success rates were far lower than usual – but this could well have been because the people on the trial had to have four blood tests to prove they had quit. (People on the trial were also enrolled without being asked, although they could opt out.) Not surprisingly, the people who were offered cash were more likely to go through the rigamarole of blood tests.
How was this reported? Publications like Cancer and HealthDay reported that cash helps people quit, but e-cigarettes don’t, despite the fact that e-cigs weren’t even the subject of the study AND that they seemed to have been combined with medicine.
What else can we look at?
Peter brought up data from the Euro Barometer. That tells us 6% of all smokers who have quit in Europe did so with electronic cigarettes. That compares to 7% of ex-smokers who quit with medicines. But quit smoking medicines have been around for 35 years – electronic cigarettes are much newer.
Looking at the balance of evidence, it is clear that e-cigarettes are by far the most popular way of quitting, and even if they are only as efficient as other aids, they are helping a lot of people. What’s more, they are doing so without costing health care systems money.
Does the reported ‘JUUL’ phenomenon change the balance of the public health impact of e-cigarettes
Professor Nancy Rigotti, Massachusetts General Hospital
Nancy Rigotti has been contributing to a report on e-cigarettes for the FDA centre for tobacco products. The report came up with the usual conclusions, for example e-cigarettes are not without health risk but are likely to be far less harmful than smoking and are likely to offer a net public health benefit.
However, the US has been alarmed by the rise of Juul. With a combination of design, better nicotine delivery and social media marketing it has rapidly become the market leader in the US, overtaking the big tobacco companies in the vaping market. (Although, as we see later JUUL’s market dominance is often overestimated.)
With a 75% increase in e cig use among high school students, which appears to be mostly JUUL, the FDA believes there is now an “epidemic” in youth vaping. The FDA is taking a number of actions, including banning sales of flavoured e-cigarettes and retail stores and gas stations and requiring age verification for online sales.
Scott Gottlieb, commissioner of the FDA, calls this an unfortunate trade-off, saying: “in order to close the on-ramp to e-cigarettes to kids you have to put in place speed bumps for adults.” Further actions such as banning sales to under 21’s are possible.
According to Nancy, if youth vaping continues to increase, models predict the long-term net benefits of vaping will decline. This raised more questions than it answered. For example, Nancy asked: Would teenagers who vape switch to smoking later (and why would they want to switch to a less desirable product)?
Just a few key points from the panel discussion. Robert West said that the evidence for electronic cigarettes is much stronger than it is for over the counter NRT aids. He also said that if you doubt that e-cigs are effective than you should certainly be calling to question many other strongly held beliefs.
And why not, said Lion Shebab. After all, e-cigs deliver nicotine and they do so more quickly and more effectively than NRT.
Farsalinos attacked the notion that smokers should be advised to avoid dual use. He raised the example of a friend of his, who used to smoke 30 cigarettes a day but now uses electronic cigarettes and smokes just 5 cigarettes a day. Is he really supposed to go back to 30 cigarettes a day because dual use is not advised?
There followed some discussion about the problems of dual use (e.g. someone who smokes at a party once a month is considered a dual user, as is someone who vapes once a month – making the term useless for scientific purposes.)
Market Impact of Regulation
Tim Phillips, E-Cig Intelligence
Tim Phillips told us that 34% of the world’s population are currently living under one or more THR bans, with 24% of the world living under an e-cig ban.
He also cleared up a misconception that JUUL has 75% of the e-cig market in the United States. This misconception has come about because more than 50% of the market (including online stores and high street vape stores) is not measured. He also pointed out that the US market is extremely fragmented, with no one brand having more than 5% of market share. Indeed, 61% of vape stores are still selling their own house liquid.
Non-tobacco flavours dominate. Unfortunately, due to upcoming FDA actions such as a potential flavour ban and online bans, the optimism in vape shops is taking a hit, with 15% very pessimistic about the current state of the vapour market and 29% somewhat pessimistic.
Tim also compared countries with strict regulations or bans with more liberal countries, and not surprising there is a huge difference in the use of e-cigs. For example, in the UK vaping prevalence is at 5.4% whereas in Australia it is at 0.7%. In Poland, where restrictions have been recently introduced, the market has shrunk by 10%. And the future for these countries? It varies from positive to bleak. In Italy there has been a change of heart with the possibility of taxes being removed while Poland is looking at new e-cig taxes.
Vaping in an Unregulated Market
Ben Youdan, ASH New Zealand
Until recently using nicotine in New Zealand was banned, although vapers were allowed to import up to three months supply of e-liquid for their own use. What changed? Philip Morris International (PMI) wanted to bring their own heat not burn product into the country. New Zealand said no, so PMI sued the government.
PMI won, and during the court case it became evident that the law used to ban vaping had been misinterpreted. Vaping took off, and it has doubled the rate at which people are quitting smoking. In contrast, tobacco industry alternatives are a miserable failure, with just 59kg sold in 2017. There have been worries about youth smoking, but e-cig use amongst youth is almost entirely limited to smokers.
Vaping is an entirely consumer driven phenomenon, and has occurred despite the government and regulators, who have a very limited understanding of e-cigarettes.
Clive Bates, Counterfactual
Clive Bates examined disruption in ten areas. These included:
Technology: The vape revolution is primarily down to advances in battery technology – it’s only increased battery capacity and life that has allowed a viable device to be invented.
Institutions: Are not responding well to vaping. In fact vaping has lead to the expression of “regulatory antibodies”. Bates covered the two types of harm institutions can make – harm from allowing something and harm from banning something. Unfortunately, institutions are focussed on preventing harm through banning something, and often fail to understand that banning something can also create harm.
Activism: Bates highlighted the numerous anti-tobacco activist groups. These appear to be funded by the public but actually have huge funds from a few key sources.
Public Health Groups: These groups simply do not like a consumer lead phenomenon that has had nothing to do with their efforts. “Vaping is an affront to the authority of public health.” Instead, Public Health feels they should be telling people what they should be doing.
Media: The media is now obsessed with click bait and generating views, which leads to ridiculous headlines such as “Vaping as bad as fags.”
Vaping products regulated as medicines
Mark Dickinson, Clarityse Ltd
Mark has a background in the pharmaceutical industry and also owns a vape shop in Tooting.
Mark pointed out that the barriers to creating a medicinal product is high. (It wasn’t mentioned in this presentation, but the Voke inhaler is a great example of this. Presenting at the Next Generation Nicotine conference earlier this week, Voke said they had spent £120 million on a medical device – and it still hasn’t reached the market yet.)
In addition to barriers, vape store customers don’t see themselves as ill. They want an alternative to cigarettes that will give them pleasure, and there is huge variation in their tastes. That means a successful vape shop needs to stock a huge variety of flavours. That would present challenges for any medical device.
What’s more, the UK market is unique, both in regulations and the way NRT products are sold (with a complicated rebate model). That would rule out many pharma companies who are interested in global solutions, and doesn’t leave many companies that would target a national opportunity. The problem is compounded by the fact that most GPs don’t refer patients to smoking cessation products. Pharma companies would also want a similar non-medical product to sell alongside the medical product, to take advantage of the branding and marketing, but UK regulations make that difficult.
Still, Mark thought that if a company could get past the barriers, the garden inside “would be beautiful.” A medical device could be lucrative and would also help more people make the switch to vaping, but any company would need government help.
A risk proportionate approach to e-cigarettes; The finding of the House of Commons science and technology committee report on e-cigarettes
Norman Lamb, MP
I won’t cover everything Norman Lamb said about vaping, as much of it will be familiar to people who follow vaping news. What was of interest was his attack on NHS trusts which do not allow vaping on premises. 40% of people with mental illnesses smoke, but in one third of NHS trusts vaping is not allowed on premises. That means when these people are in-patients, a golden opportunity to get them to quit smoking is lost. Norman has called for the NHS to have a clear central policy on mental health and vaping to address this.
He was also harshly critical of smoking shelters that have been designed for smokers and vapers, calling it a very stupid decision to put the two groups together. He concluded by saying that vaping had helped thousands to stop smoking, was substantially less harmful than smoking, and could save tens of thousands of lives – especially in the field of mental health. He called for a debate, especially on vaping in public places (e.g. on trains), but for a debate which is evidence-backed, not based on emotion.
Norman Lamb expanded on his previous statement, saying that health opposition to vaping was based on prejudice, not fact. He also called for NHS England to take responsibility for vaping instead of leaving it all to Public Health England. On medical devices, Tim Phillips said that commercial companies have done the maths and decided it wasn’t worth it. Lamb also attacked the cautious approach of organisations such as the Lancet, saying it would cost many lives.
Reasonable public health professionals still have concerns about e-cigarettes and tobacco harm
Martin Dockrell, Tobacco Control Lead, Tim Marczylo, Principal Toxicologist, Public Health England
Martin Dockrell admits he is very positive about e-cigarettes, but there may still be some reasonable concerns. In this discussion he attempted to ‘receive’ the concerns of his colleagues.
First up was animal studies. Scepticism is often expressed about the validity of animal studies. However Tim said that we should carry out studies where there might be concerns. If we find something, it doesn’t mean it will be a problem in humans, but it does means we can investigate the problem further. Furthermore, some tests can’t be carried out on humans. There’s also the matter of cheating – humans clearly do cheat sometimes but animals can’t.
Martin challenged Tim over the effect of nicotine on the adolescent brain. After all, if nicotine causes brain damage why aren’t all former teen smokers (including Martin) brain damaged. (A show of hands in the room showed many had smoked as teenagers.) Tim said there might not be brain damage, but there could be changes in neurotransmitters, which could lead to very subtle differences.
Second hand vaping was also covered. So far analysis seems to show there is a very low risk, but some people with asthma can have reactions. Passive smoking is usually talked about in the context of of lung cancer and heart disease but it’s worth remembering that there are other reactions – and also that other substances, like aerosols and after shave, can cause asthma reactions.
Salford Swap to Stop Pilot – free e-cigarettes to support 1,000 smokers with their quit attempt
Kuiama Thompson: Rochdale Borough Council
Salford decided to try an interesting experiment – to see what would happen if they gave 1000 vape starter kits away. They offered three device options, 4 flavours and 2 strengths, but Kuiama emphasised that if she repeated the experiment she would like to offer more choice.
The results? At four weeks, 63% of those followed up had quit smoking. The most successful demographic was the most deprived. They found no significant difference between the devices used, and that fruit flavours were the most popular (and becoming more popular as the trial progressed.)
Kuiama emphasised that while many smokers have quit, these are hardened smokers, and a key factor in the success of the strategy was the fact that e-cigs were free.
According to Kuiama Thompson, Salford stop smoking services have had great success with their 1000 starter vape kit pilot scheme. Other councils should take cues from this good work #ecigsummit pic.twitter.com/UBdenQBIjt
— ECigaretteDirect (@ECigDirect_UK) 15 November 2018
The Kids Are Alright: Halting the intergenerational reproduction of smoking means helping older adults to quit
Dr Frances Thirlway: University of York
There’s a moral panic about children who vape taking up nicotine. But the fact is that kids turn into their parents. That means middle class children will mostly quit smoking or vaping while many working class kids will take up smoking. This has implications for Juul. As it’s expensive, Juul is a middle class trend and ultimately these kids will quit Juul.
The working classes also smoke for different reasons. For many in these groups, smoking is about identity and belonging to a group of people. Quitting smoking can be seen as betraying the group or family, and indeed some quitters have been shamed or bullied into taking up smoking again.
How do you deal with this? Not by addressing health directly, as it’s not as much of a moral priority for the working class. Instead, successful marketing avoids individualistic marketing and focuses on other working class values such as family.
We also need to focus on entire families and communities, as it’s only by getting the older generation to stop smoking that you can avoid kids taking up smoking. This is where electronic cigarettes can help.
Perceptions and misperceptions: Communication has become a battleground
Sarah Jakes, Vaper and Board Member, New Nicotine Alliance
Sarah covered the confusion amongst vapers, who are faced with the fact that vaping evidence is often purposefully misrepresented. What’s more, most people don’t follow the evidence, but only see discussion of vaping when something hits the news. What happens? Many people are confused, and it’s just easier to stay with the status quo i.e. smoke.
The US is a perfect example of this. Sarah covered Juul, and asked whether the rise of Juul had been accelerated by the FDA’s reaction. After all, if you’re a rebellious kid, the FDA’s alarmed reaction could increase the attraction.
Fortunately, the UK’s attitude is very different. But it is still a difficult environment, and critics tend to attack by claiming vape advocates are tobacco shills, in an attempt to shift the debate away from the evidence.
Harm reduction veterans have seen all this before and say there is always opposition in the early days, but in the end common sense will win.
I’m sure that everyone will come away with their own conclusions, but the biggest impact on me was the total and utter failure of the world’s governments and public health to serve smokers. Take Snus, for example. It’s clear that Snus in Sweden and Norway has lead to the lowest rates of smoking and smoking related disease in Europe (if not the world!), despite the best efforts of tobacco control. Yet it’s banned in almost all of Europe. This has likely cost millions of lives.
New Zealand is another example. After vaping was legalised by accident, quit rates doubled with zero intervention from the government. How many more people would have stopped smoking earlier, and how many lives would have been saved, if the government had done nothing?
Far from learning lessons from the Swedish and Norwegian experience, regulators and public health are determined to take control of another success story that has never been about them: vaping. This control takes different forms. Australia, for example, has put in a complete ban while in other areas regulation is more paternalistic.
Where draconian regulations have been put in place, they have slashed quit rates and will almost certainly lead to untold numbers of early deaths. But even in countries where more paternalistic control is sought, public health can still do damage. Vaping works because it is fun, enjoyable and caters to the individual. Any attempt to alter these factors could affect the success of vaping.
I lean towards Clive Bates. We do need some sensible safety requirements (e.g. testing e-liquids for harmful substances), but other than that, public health and governments should just butt out and let consumers and industry get on with it.
Not all is gloom! The UK is leading the world when it comes to vaping. We can be proud of our country for a liberal and sensible approach that is allowing vaping to reach its full potential.