- THR and Public Health Policy
- Nicotine policy in England: Recent developments and future plans to make smoking obsolete
- Medicinal licensing for e-cigs: Why England is the frontrunner not an outlier
- The 2021 review of NICE’s tobacco guidelines
- Combustible tobacco age of sales: An opportunity?
- The potential role of the cigarette industry in the future of the e-cigarette market
- Panel Discussion and Q&A
- Research & Policy
- Nicotine and Public Health
- Shifting the paradigm: Tobacco control and THR are scientifically complementary approaches to reducing illness and saving lives
- Parents: The untapped resource for balancing cessation and prevent needs
- Greater Manchester is making smoking history
- The key role of vaping in medical practice. Time for doctors to get on board
- Closing Keynote: Covid-19 and tobacco harm reduction: Are there lessons from the pandemic for the way ahead?
- Panel Discussion and Q&A
THR & Public Health Policy
Nicotine policy in England: Recent developments and future plans to make smoking obsolete
Rosanna O’Connor, Director, Addictions & Inclusion
Smoking rates are falling - but not fast enough. Interventions have made a very significant impact, but if we don’t up our game and go faster we will not reach the UK’s 2030 Smoke Free goal.
E-cigarettes remain the most popular quit aid, but rates of e-cigarette use remain unchanged since 2013. Rosanna is proud that regular e-cigarette use amongst children remains very low, showing regulations do work.
Success rates when using e-cigs in Stop Smoking Services (SSS) are very good. The problem is, only 6% of clients in SSS actually use e-cigarettes. We need to do better in the stop smoking space, using e-cigarettes to help smokers, especially those who are heavily dependent.
It’s interesting, given the Australian approach to vaping until now, that the Australian government asked the UK to give a webinar on using vaping to quit smoking for doctors. Prescriptions in Australia were also mentioned as a positive [presumably in contrast to a total ban].
Rosanna also touched on medical prescriptions for vaping. Applications will be treated in exactly the same way as other medicines - in other words, don’t expect to see anything soon. Still, Rosanna believes these are necessary for three reasons:
- to increase access for disadvantaged smokers
- the potential for higher nicotine strengths for the most dependent smokers
- to provide reassurance to both the public and professionals on safety and effectiveness.
Another positive development is that NICE (The National Institute for Health and Care Excellence) will advise vaping is a safe and effective option for quitting smoking. At the same time, there will be new guidance for Stop Smoking Services in December which will both address common misconceptions and concerns, offer better guidelines and hopefully increase the availability of e-cigarettes. Case studies will also be provided for more cautious stop smoking services.
A new tobacco control plan will come in 2022, but before that the Vaping in England 2022 report will come out. This will be the largest review so far.
Medicinal licensing for e-cigs: Why England is the frontrunner not an outlier.
Deborah Arnott, Chief Executive, Action on Smoking and Health (ASH)
There are conflicting views on medicinal licensing on vaping. Some think that it will be simply a matter of submitting existing consumer products for licensing, while others think the bar will be so high that no e-cig company will be able to reach it.
The reality is somewhere between this - products will need to be produced to medicinal standards, but the process will still be much easier and cheaper than normal, costing an estimated 3-5 million pounds instead of 10 -15 million. Still, don’t expect to see any licensed products until at least 2023. First movers will have the hardest task, but will also reap benefits.
Why do we need medicinal e-cigs? Vaping has plateaued in the UK. 30% of smokers have not tried vaping. Part of the reason is that smokers’ perceptions of harm are distorted. Around 1/3rd of smokers believe that e-cigs are as or more harmful than cigarettes. There are other benefits too. For example, medicinal products can be taxed at a lower rate (5% not 20%) and can be advertised.
Previous experience also shows prescriptions can lead to rapid growth of nicotine products such as NRT. Licensed e-cigarettes have the potential to grow the market to the benefit of smokers, producers and public health.
The 2021 review of NICE’s tobacco guidelines
Paul Lincoln: Chair - Tobacco: preventing uptake, promoting quitting and treating tobacco dependence - National Institute of Clinical and Health Excellence (NICE)
Paul Lincoln spoke to explain NICE’s guidance on e-cigarettes. The guidance is based on both consultation and a very comprehensive review of evidence and research. This evidence is reviewed and analysed by a committee of experts, practitioners and lay members. Much of the research produced for this guidance will be published in peer reviewed journals.
There are two aims with young children. 1. To discourage young children and adults who do not smoke from experimenting with e-cigarettes. E-cigarettes should not be discussed when discussing tobacco. 2. When talking about e-cigarettes to young children and adults who do not smoke it should be clear why people who do not smoke should not use them.
[Note: It is interesting to notice the emphasis on discouraging children who don’t smoke from vaping, rather than all children, which is what we usually see.]
On smoking cessation, it is important to ensure that nicotine e-cigarettes are available, that they (and other cessation treatments) can be combined with behavioural support and that people understand that e-cigarettes are one of the most effective ways to stop smoking. People should also be given accurate and up-to-date information on vaping and the comparative harms to smoking.
Smokers should also be given advice on vaping, which includes:
- ensuring they get enough nicotine to overcome withdrawal symptoms
- using e-cigs long enough to quit smoking
- getting advice on how to stop vaping when they are ready.
Paul also summarised areas that needed further research (with the biggest gap being harm reduction). Paul said that NICE felt that e-cigs were a 10 year experiment in the UK. There have been no adverse effects yet, but it’s important to keep monitoring. There is also the potential for a profound impact on tobacco related health inequalities.
Combustible tobacco age-of-sales laws: An opportunity?
Dr Michael Pesko, Health Economist & Associate Professor, Georgia State University
There is a concerning trend of people grossly overestimating the risk of e-cigs compared to combustible cigarettes. In 2012, despite less research, 40% of people believed vapes were less harmful. In 2020, only 10% believed e-cigs are less harmful. The science is getting stronger, and supporting e-cigs being safer, but public perception that e-cigs are at least as harmful or more harmful than smoking is growing.
The costs of misperceived risks are:
- kids may use cigarettes more
- adults may be less successful quitting smoking.
Natural experiments show that:
- e-cigs reduce smoking amongst all groups
- restrictions on e-cigs lead to an increase in smoking rates. [See our analysis here.]
What’s behind misperceived risk?
One is the naming of EVALI (E-Cigarette or Vaping Associated Lung Injury). Only 28% of respondents correctly linked it to THC in cannabis.
Governments also over-emphasise the risks of e-cigs, especially to kids. But is it ethical to provide different information to people depending on their birthday? How will they correct misinformation when kids become adults? If kids feel they have been deceived, how will this impact their future trust of the government when they actually do need to trust it (for example, in the case of a global pandemic)?
Possible solution: Combustible 21
Combustible 21 would increase the minimum legal age for cigarettes to 21 - but not for vaping. Pesko estimates that if this had been done in the US, there would have been a 4.5% decrease in smoking among 18-20 year olds (as compared to a 3.6% decrease with a general ban) and a 3% increase in e-cigarette use.
As long as e-cigs are less than 1/3rd as harmful as cigarettes, there would be a net health benefit. However, the main public benefit would be the messaging (vaping is safer than smoking) which could benefit all population groups.
The potential role of the cigarette industry in the future of the e-cigarette market
Professor David Levy, Professor of Oncology, Georgetown University
Until recently, due to high barriers to entry and uncompetitive behaviour, the cigarette market has only been composed of a few firms. This led to a profitable and uncompetitive industry. Things were simple, and the enemy was clear.
In recent years, though, things have changed. Consumers are now buying other forms of nicotine delivery (smokeless tobacco and e-cigarettes) and in different ways (online, vape shops). Tobacco companies have only succeeded in getting some of this market - they dominate in the mass retail market, but not online or in vape shops.
The result is a more competitive market, which can now be defined as the nicotine delivery product market rather than the cigarette market. It also means the enemy is less clear to tobacco control advocates.
In contrast to stability pre-2005, there has been a rapid decline in cigarette use, especially amongst youth, and a rapid increase in e-cigarette use. In the future, cigarette companies are likely to focus on Heat Not Burn (HnB) and smokeless tobacco, as they rely more on proprietary technology and reputation and are sold in retail stores.
Public policy will be key to future developments. Now there are alternatives, there is a stronger justification for potent policies to encourage companies to switch to reduced harm products. However, e-cig policies have had mixed effects. Negative policies (e.g. flavour bans) will reduce innovation and slow the substitution of vaping for smoking. Pro-harm reduction policies, such as those in the UK, will increase the use of e-cigs and heated tobacco products.
Current US policies will discourage vaping and encourage smoking, but as the negative consequences become clear, David expects the country will come back in line. Less-harmful products will continue to replace smoking, but the impact and speed will ultimately depend on competition from e-cigarette companies, which will encourage tobacco companies to promote reduced harm products in order to ‘stay in the game’.
- Louise is shocked that less than 6% of health care professionals use e-cigarettes. Often this is because they are stopped higher up the chain.
- It’s great that there is advice for stop smoking service. But we mustn’t forget how much undermining comes from stop smoking professionals who don’t get the message. Just last week one professional advised a stop smoking client that they would be better off smoking.
- On asking how long someone intends to vape for - this is very tricky. Usually people have no idea, assuming the less they use a vape the better. It’s only through growing confidence in staying smoke-free that they will have a better idea. Louise is really pleased to see advice on using enough nicotine, as most people fail to quit because they don’t use enough.
- If people are lied to about vaping, why should they believe what they are told on other health matters?
- Young people who smoke should be allowed to buy a vape at a younger age so they don’t smoke.
- A question: Will the US distrust of tobacco harm reduction reduce while there is still generous funding from certain prohibitionists?
- At each summit, the crushing sense of opposition to tobacco harm reduction has become utterly depressing, but at this summit Louise is really encouraged by the number of organisations that actually listen to smoking. The message from England that vaping displaces smoking cannot be ignored.
Panel Discussion and Q&A
Speakers: Martin Dockrell, Rosanna O'Connor, Deborah Arnott, Paul Lincoln, OBE, Dr Michael Pesko, Prof David Levy
Is England an outlier or a trailblazer?
David said England has definitely been a trailblazer. The country has fewer restrictions, but the restrictions have been sensible. The US had no restrictions for a long time but the PMTA could give back control of the nicotine market to tobacco companies - which would be a disaster. Watch 2 other countries for competition - New Zealand and Canada.
Rosanna said it’s important we stick with our ambition and courage, because we will not hit smoke free targets if we don’t ramp up people using e-cigs to quit. Deborah argued that England’s success is due to combining implementation of the WHO FCTC with an acknowledgement of the role e-cigarettes have in supporting cessation. Ecigs are not a silver bullet - they are part of a comprehensive approach. We also need to have humility in the global settings. In the poorest parts of the world the epidemic is still starting. Their problem is not cessation, it’s stopping people from smoking. Encouraging e-cigs is not the only way forward. What works for us will not necessarily work for other countries.
Medicinally regulated e-cigs
Deborah doesn’t think tobacco companies will be the first, or have the appetite, to introduce medicinal vapes. If they are first, the guidance on use needs to come from trusted sources. Both pharmaceutical and tobacco companies have abused guidance on use in the past.
David thinks the cigarette industry will try to reach out its tentacles. They can deal with the bureaucracy involved. The last 5 years have shown they will do whatever it takes to stay in the nicotine delivery market. We need to be very cautious and monitor the tobacco industry closely.
New NICE guidelines
Louise says NICE guidelines will give assurance to people who were very hesitant, and will help people who find it difficult to get the money together for a starter kit. David added that there is potential for other products to help too. For example, Heat Not Burn products, while less desirable, could help smokers for whom e-cigs have not worked. The emphasis should be on e-cigarettes, but don’t exclude other potential avenues. Remember the real culprit is cigarettes.
Combustion 21 (Raising cigarette age limit to 21 on combustible tobacco only)
David discussed claims that e-cigs are a gateway. If you look at real trends, cigarette use has fallen unbelievably. Take 12th graders - the daily cigarette rate was just 12% by 2019. Among 18-24 year olds (2012-18) smoking rates fell by 60%.
Can we say this is definitely due to e-cigs? No, but it is hard to imagine they haven't played an important role and it does seem that norms have drastically changed in youth and adults - away from cigarettes and potentially towards e-cigarettes.
However, Deborah thinks that in the UK we can’t make a distinction between combustible and non-combustible products. Snus legality is not going to happen and Deborah doesn’t see any need as there are nicotine pouches. Heat Not Burn is basically a model for the tobacco industry to maintain dominance of the market. She doesn’t want to open the market so the tobacco industry can try and destroy e-cigs.
Research & Policy
E-Cigarette Research: Misinterpretation and selective use of evidence guiding regulatory decisions
Dr Konstantinos Farsalinos, MD, MPH, External Research Associate, University of Patras
Konstantinos focussed on cherry picking, which can refer to either suppressing evidence or presenting incomplete evidence. This can be either intentional or unintentional (confirmation bias).
Konstantinos uses the example of studies measuring emissions in e-cigarettes v. tobacco cigarettes. Studies found high levels of amelhydes in e-cig emissions. However, when Konstantinos tried to replicate this he found amelhyde levels were much lower.
One of the reasons the original study got it wrong included using unrealistic conditions (using burnt coils). They also used old devices, not modern devices [which produce less emissions than older technology].
Links between e-cigarettes and myocardial infarction were also made in a separate cross sectional study. However, you can not use cross sectional studies in this way. To demonstrate why, Konstantinos used the same methodology to look at cholesterol lowering medicine and coronary heart disease. That methodology led to the conclusion that cholesterol lowering medicine causes myocardial infarction.
Of course, that’s not the case - the reality is that these people were taking medicine for heart disease and were therefore more likely to have heart attacks. It’s the same for vapers - most have smoked or are still smoking, and are therefore more likely to suffer disease.
A third example is confusing the short term and long term impacts of vaping. Vaping leads to arterial stiffness. But so does caffeine. Both only do so in the short term. This is an acute effect, not a long term (chronic) effect. In fact, just 4 weeks after switching to vaping arterial function improves. However, the positive studies about this have been ignored.
In conclusion, cherry picking is a major issue in e-cig research. It can damage public health if it is used to drive decisions. That’s because misinformation:
- discourages smokers from switching
- provides false information to those prone to risky behaviours
- leads to a risk that former smokers will abandon e-cigs and revert to smoking.
Scientists, organisations and media have an important role to play in presenting evidence in a balanced and unbiased way, avoiding sensationalist/emotional headlines that do not represent real findings & ensuring the totality of evidence is presented.
Absolute and relative risks of e-cigarettes
Professor Alan Boobis, OBE, Emeritus Professor of Toxicology, Imperial College London
Professor Alan Boobis is chair of the Committee on Toxicity of Chemicals in Foods, Consumer Products and the Environment (COT), which has reviewed both absolute and relative (compared to cigarettes) risks to health from ENDS.
By far the major constituent in e-liquid is the vehicle, which is almost always propylene glycol, glycerine or a mixture. This is relatively non-toxic over the short to medium term, both in terms of the absolute and relative risk and to both users and bystanders. There is some uncertainty over long term use, especially for heavy users.
Flavourings were also considered. Once in the body, these have the same effect as being ingested except for the possibility of direct effects on the lung. The evidence so far shows no indication of harm. However, there are a wide range of flavourings and more evidence would be helpful. Some flavours such as cinnamaldehyde, are potential sensitisers. We don’t know if this could be a risk to some users, but it doesn’t appear to be a major problem.
There have been concerns about the impact of heat on flavours. In fact, degradation at vaping temperatures is low. Indeed, many of these flavours are heated when cooking - without adverse effects. It’s possible there may be some local effects on the lungs, but in general exposure is low and adverse effects are not anticipated. The COT has developed a framework for risk assessment of flavour which is included in the MHRA guidance for licensing products.
The problem with cigarettes are contaminants generated in tobacco. These are either not present in e-cigs or are found at much lower concentrations. For example, tobacco specific nitrosamines, which are particularly toxic, are present in e-cigs at 0.3% of the levels of cigarettes. Heavy metals are also present in cigarette smoke, but are either not detectable in e-cigarettes or are at extremely low levels. Many of the problematic ingredients in e-cigs, when present, are at the same or slightly higher levels than those found in background air.
Alan went on to look at vapour in an indoor setting. Nicotine and particulate matter (PM2.5) are much, much lower than those generated by smoking. It is possible that people who are consistently around a very heavy user may experience some exposure to nicotine and particulate matter leading to pharmacological effects. However, this only applies to a small number of heavy users. Furthermore, many of the particles generated by vapour are soluble, and are likely to have less effect than the insoluble particles generated by cigarette smoke. More work is needed to understand particulate matter and its effects.
In conclusion, Alan highlighted that e-cigs are not without risk, so should not be a lifestyle choice, but that the risks to bystanders were low to very low. He also highlighted that population studies fail to take into account prior smoking, which makes them very difficult to interpret.
Nicotine and pregnant smokers
Professor Peter Hajk, Professor of Clinical Psychology, Queen Mary University of London
There are very different attitudes in the UK and the US. The UK advises pregnant women that vaping is much safer than smoking. The US advises pregnant women that vaping is no safer than smoking.
Why does the US think this? The focus in the US is on the harm from nicotine, which the US has linked to low birthweight, harm to lungs and organs and so on.
Peter looked at the impact of smoking on the brain and behaviour. He noted that the harm of nicotine to the brain is a relatively new concept and is contrary to previous opinion. This new perception is due to recent animal studies that found that nicotine can cause substantial damage to animals. However, these studies are problematic, as they used very large nicotine doses combined with considerable distress to the animals.
A number of studies, which account for the differences in the background of the mothers, found that smoking in pregnancy does lead to lower birth rate. It probably also causes other negative outcomes such as miscarriage and stillbirth, although smoking is likely not the only factor. It does not lead to intellectual disability. For example, differences in IQ amongst smokers’ children was found to be related to the mother’s IQ, not smoking.
There is little data on vaping, but what data there is suggests there is little or no effect on infants. A recent large study looked at vaping v. nicotine patches. There was no difference in outcomes other than for lower birth rates in women using patches - this is likely due to higher smoking rates in the patch cohort. The study also compared quitters who vaped with women who quit nicotine entirely. There was no difference in birth weight, and infants in these groups were heavier than those in groups who continued to smoke. The data so far shows that nicotine in late pregnancy does not negatively affect infants.
In conclusion, nicotine does not seem to have any impact on late pregnancy (more data is needed on early pregnancy). Quitting without nicotine may be preferable. However, if this is not possible vaping is a better option than smoking.
Depression causes vaping!
Professor Caitlin Notley, Chair of Addiction Sciences, University of East Anglia
A recent Truth Initiative report, despite flaws, drew attention to a high incidence of poor mental health amongst young people, and that a proportion of those young people are using nicotine. It claims these mental health issues have doubled, which appears to be true. While this may be genetic, it is likely also related to the pandemic and socio-economic factors.
Vaping is often portrayed as an epidemic.
What is an epidemic? It’s the rapid spread of disease to a large number of people in a short period of time. It’s also a term deployed to generate an emotional reaction from groups in the public - especially parents.
However, youth vaping in the US, though higher than in the UK, is reducing. What’s more, most of those young vapers are former smokers.
But if youth vaping is not an epidemic, what is it? It’s a behavioural practice that is socially important. It’s self soothing and may have a positive function for individuals who have mental health issues.
There does appear to be a relationship between mental health conditions and smoking. But there is also a link between inequalities and mental health. It’s a complex mixture of multiple interlinking factors.
How is this interpreted? We can see that there are increasing rates of mental health problems, and stable or decreasing rates of youth vaping. The Truth Initiative headlines (not the report itself) link nicotine and vaping to depression. They then launched a marketing campaign selling ‘depression sticks’ to highlight this association.
This is dangerous. This is scaremongering. Campaigns like this can assign moral panic. This is a campaign not based on evidence, but a campaign driven by fear. It directs public attention to banning the problem and it scapegoats the behaviour rather than dealing with the very real and deeply concerning issue of poor youth mental health.
It’s easy to say vaping causes depression. The reverse could also be true. More likely it is birectional.
Nicotine stimulates the release of dopamine in the brain, causing positive feelings. People with depression have low levels of dopamine, and may use nicotine to temporarily increase their dopamine supply. There are also complex social and psychological aspects to vaping that may also be beneficial or pleasurable to young people.
The next part of the talk is perhaps best summarised by Prof. Notley’s slides:
(CMDs - Common Mental Disorders)
The impact of the Covid-19 pandemic on e-cigarette and tobacco use in the UK
Dr Lion Shahab, Professor in Health Psychology, University College London
The UK government wants to be smoke free (i.e. below 5% smoking rates) by 2030. At current rates, though, it looks like it will be 2038 before it achieves its goal. Has the pandemic helped or hindered this goal?
Dr Shahab then took us on a whirlwind review of the data. I’ve listed some of the key points below.
- There was a big switch to ordering online for both vaping and cigarettes. There was also an increase in illicit tobacco purchases.
- More smokers accessed quitting support during the pandemic.
- There was an increase in both cigarette and vape consumption in the early stages of the pandemic, but this later levelled off. Strangely, there did seem to be a decrease in home consumption [which makes one wonder where people were consuming more cigarettes in lockdown!]
- Covid motivated smokers to quit, but vapers were less motivated to quit than smokers. This led to an increase in both quit attempts and successful quits.
Particularly interesting is switching patterns in the pandemic. More dual users (who both smoke and vape) became exclusive smokers than became exclusive vapers. Some vapers also moved away from using vaping for cessation to dual use. This may be due to vape shop closures. [This reflects stories we heard post-lockdown, with some customers telling us they reverted to smoking while shops were closed.]
E-Cigarette use, on the other hand, increased in prevalence. This could be due to ex-smokers starting to vape or by the fact that current e-cigarette users are not quitting vaping. It might also be influenced by the fact that some reports suggested that nicotine could have a protective effect against Covid-19.
Overall, there has been some decline in smoking rates. This reflected a much more pronounced decline in daily smokers, and an actual increase in non-daily smokers, which might be caused by vapers picking up a cigarette during vape shop closures. Overall there has been an acceleration of the decline in smoking rates, with the expected year to be Smoke Free now 2037 instead of 2038.
Panel Discussion and Q&A
Speakers: Prof Robert West, Dr Konstantinos Farsalinos, MD, MPH, Prof Alan Boobis, OBE, Prof Peter Hajek, Prof. Caitlin Notley, Prof. Lion Shahab
To avoid this becoming the longest blog post in the world, I’ve had to cut out quite a lot from these panel sessions. That’s especially the case with this one, but I do highly recommend listening to the whole thing if you are able to, as it was a fascinating discussion. Here’s a few of the key points...
On the WHO statement that e-cigarettes are harmful to health...
Caitlin said the WHO is a globally respected body, and the public look to them for reassurance. It’s really concerning that the WHO put across a simple, non-nuanced message which could prevent people from switching away from cigarettes to less harmful forms of nicotine. There’s also no evidence that vaping is harmful to mental health outcomes. Peter said the statement was misleading and misguided, driven by ideology not by evidence. Lion argued that the WHO statement is meaningless, as anything can be harmful to health, including ibuprofen or water.
What should tobacco control groups do or say to better influence the public?
Caitlin said that the message around vaping and mental health should be the same as the general message: vaping is a less harmful way for people to continue to use nicotine. Konstantinos argued we just need to be honest in communicating the evidence, including the unknowns - and avoid cherry picking. This will convince millions of smokers to switch.
On the long term impacts of vaping
Alan suggested looking at the problem from first principles. What’s the likelihood of this product causing long term harm? It’s not a complicated product compared to a cigarette. We have also now accumulated quite a lot of experience from over 10 years of significant use. If there are long term health effects, they will be signalled by precursors - but we are not seeing precursors or evidence of harm at all.
On aldehydes in e-cig vapour
Konstantinos said that diluents in e-liquid can be transformed by heat to toxic compounds, particularly aldehydes. However, we are exaggerating the real risk because the levels are minimal (at least 99% lower) when compared to a tobacco cigarette. For example, we get more formaldehyde from inhaling air in our homes than from an e-cigarette. There are other things which we can improve - and indeed have been improved over the years thanks to a rapid evolution of vape devices. Alan added that there are no signs of aldehyde toxicity in vapers over many years of use. He sees many hypothetical questions which don’t take into account how the device is constructed and used.
Are misleading articles intentional or unintentional? (A question from Lion to the rest of the panel.)
Konstanitonos suggested misleading articles are primarily down to ideological opposition to nicotine and harm reduction, combined with some intentional manipulation of methodology in a small number of cases. It is very easy to manipulate e-cig studies to ensure the results will be bad, for example by overheating the devices.
Alan suggested it was a mixture of intentional and unintentional factors. He added that these studies, until replications are done, cause a huge problem for the assessors. While a misleading study is waiting to be replicated, hardliners use it as evidence. Caitlin said the media is intentional about how they report findings, as shock horror headlines sell papers. She said the media don’t care about the science, they just want to make money.
Nicotine and Public Health
Shifting the paradigm: Tobacco control and THR are scientifically complementary approaches to reducing illness and saving lives
Clifford E. Douglas. Director, Tobacco Research Network
The tension between Tobacco Control and Tobacco Harm Reduction is often cast as a ‘good and evil’ battle - but both sides have enough shared goals to be able to find common ground.
The FDA’s authorization of some ecigarettes & non-combustible products proves their scientific determination that alternative nicotine delivery products are significantly less harmful. The FDA has made clear that they are also appropriate for the protection of public health and can help smokers quit.
What is taking place now holds the potential to enable the transition to a new era where adult consumers can access far less harmful alternatives and develop a more accurate understanding of nicotine's risks and benefits.
Tobacco Harm Reduction is about science and the realities of human behaviour, not an industry plot. Evidence-based harm reduction programmes work in other areas to reduce illness and save lives (e.g clean needle programmes help prevent HIV, Hepatitis C and death). When managed properly, they help public health.
To pursue THR effectively the process must uphold objective, non-politicised enquiry and review. Policy should be based on credible science, not preconceptions and misconceptions. Policy-based science must be developed to better educate the public, public health/medical communities, the media and decision makers.
Smokers shouldn’t have to die because they don’t know there are less harmful sources of nicotine. Significant misperceptions persist among the public and health care professionals re: the role of nicotine. It is depicted as Public Health Enemy #1 and this deters smokers from NRT. If we continue to live in a world where nicotine is believed to cause the deadliest tobacco-related illnesses we’ll have a very difficult time succeeding.
Major stakeholders (Public health/TC advocacy organisations and academic communities) can step up to provide information and education. Many do this by writing to the media, CDC, FDA, WHO & White House - with no connection to the tobacco industry and without serving its interests.
100+ independent global experts on nicotine science and policy recently sent an open letter to all nations involved in the WHO FCTC. This encouraged promotion of THR and criticised the WHO for misleading the public on the relative risks of different tobacco products and for aggressively rejecting a strategy that could prevent millions of deaths. Yet, a response from one delegate was to imply that the experts were a front for the tobacco industry - a sad and counterproductive misrepresentation.
The debate is often wrongly depicted as Public Health vs Tobacco industry. The Public Health side attributes Harm Reduction advocacy and any science that lends credence to THR to the influence of industry. This leads to a simplistic ‘us and them’ debate where THR advocates become tools for the tobacco industry.
Suspicion of the Tobacco Industry is warranted and it should not be taken at its word. Don’t trust, Verify!
What ultimately matters is meaningful and effective action in a well regulated marketplace.
Parents: The untapped resource for balancing cessation and prevent needs
Professor Robin J. Mermelstein, PhD, Distinguished Professor of Psychology & Director, Institute for Health Research and Policy- University of Illinois, Chicago
There is a strong association between parents and children smoking. If parents quit, their children are less likely to smoke - but are still more likely to smoke than the children of non-smokers.
Robin outlined the importance of parents and explores conversations parents can have with their children to discourage them from smoking. Parents may need help to quit smoking, but they also need help in ‘effective message delivery and content’ for their children.
Robin went on to explore what happens when parents vape, but with a lack of data, much of the talk explored hypotheses. It’s clear that vaping has the potential to help with the problem of smoker’s children taking up smoking. Unfortunately, many people are concerned about the safety of electronic cigarettes, which makes them less likely to use vaping. One solution for parents concerned about this is to put some rules in place, such as only vaping outside.
Greater Manchester is making smoking history
Andrea Crossfield, MBE, Population health policy and strategy specialist
You can’t reduce health and wealth inequalities without tackling smoking. So Greater Manchester has set ambitious targets to reduce smoking, leading to a potential one billion pounds more in smokers’ pockets. One of the ways to achieve this is via its far-reaching electronic cigarette program.
These include e-cigarette pilots, which delivered free kits to areas of the city. For example, they delivered 1000 kits to a social housing area, which led to a 4x increase in both quit attempts and successful quit attempts. E-cigs have also been key to reducing smoking among pregnant women, with 40% of those who quit doing so with e-cigarettes. This helped contribute to the largest drop in smoking amongst pregnant women in the UK, with over 1000 additional babies born to women who used to smoke but quit.
Manchester will be working in hospital settings too, which includes giving away e-cigarettes at some hospitals and allowing vaping on hospital grounds. The ultimate goal is to integrate e-cigarettes into all settings. Working with rough sleepers has been more challenging - many homeless smokers go on to dual use rather than exclusively vape. However, there have still been positive results, such as homeless people feeling they have more control.
Andrea went on to share several stories of people who had been helped by vaping, before sharing a series of learnings and recommendations from Greater Manchester’s experiences:
- people need a range of choices: e-cigs, meds, NRT
- people are often put off if they have tried to quit before
- people want to see e-cigs as a valid stop smoking aid - licensing would help
- people want comprehensive support from e-cig friendly services
- people want education on how to use e-cigs, and how to prevent dual use
- people want the facts around e-cig safety
- alternative offers are important for people who want to quit alone e.g. digital app and informative health content.
Andrea also argued that it is important to win the hearts and minds of all stakeholders. She concluded that to empower people to quit smoking, we need to provide information, choice and motivation. [VapeSmokeFree, which is provided by the Independent British Vape Trade Association (IBVTA) and which I have contributed to, is one source of information for both smokers and Stop Smoking Services.]
The key role of vaping in medical practice. Time for doctors to get on board
Dr Colin Mendelsohn, Chairman, Australian Tobacco Harm Reduction Association/ Author - Stop Smoking, Start Vaping.
Smoking cessation is a key responsibility of medical practitioners. Patients see GPs as a credible source of information but there are lots of competing priorities and missed opportunities. Low quit rates are a problem, even with the best treatments - many smokers try and fail. This is very discouraging to both patients and medical practitioners.
Harm Reduction strategies are routine in medical practices (e.g. with drugs and alcohol). Vaping ticks all the boxes as a harm reduction method and is the most effective quitting aid. Smokers who switch to vaping have improved health, reduced toxin exposure, save money, and both smell and feel better.
Yet most doctors are unsupportive of vaping. They are poorly informed, have concerns about effectiveness, safety and addictiveness and few recommend it to patients. There is little training available and they tend to get their information from the media and patient feedback rather than scientific research.
Nicotine use represents minimal risk of serious harm to physical health yet 4 in 5 US doctors wrongly believe it contributes to cardiovascular disease, COPD and cancer. Doctors have a duty of care to keep their knowledge up to date and not allow their moral views to deny patients access to medical care. But they are mostly failing in this. Fortunately, Australian GPs who have started prescribing vaping are getting great feedback from patients.
Disadvantaged communities see higher smoking and relapse rates, more addiction and lower quit rates. Smoking is a major cause of financial and health inequalities - with many smoking to cope with stress. As traditional methods are less effective, new and effective strategies are needed. Vaping is getting a lot of interest and high uptake in these communities and has big health and financial benefits.
Closing Keynote: Covid-19 and tobacco harm reduction: Are there lessons from the pandemic for the way ahead?
Linda Bauld, OBE, University of Edinburgh
Just as with Covid, at the start of the vaping era there were many unknowns. Because of this, many countries did not know how to regulate or respond to vaping. For example, we didn’t know the relative risks or whether they would help people to stop smoking.
With both Covid and vaping, building evidence has been crucial. Investment has transformed what we know about vaping, and has informed policy decisions. However, this has been underfunded and concentrated in high-income countries. Another common factor is who matters in each debate:
The role of the WHO has also been different. They have played a leading role in the pandemic, but in vaping their position has been very controversial.
The media has played a big role in both vaping and Covid-19. The coverage hasn’t always been accurate or helpful. It’s the bad news that makes the headlines (e.g. people breaking the Covid-19 guidelines, not those who follow the guidelines), but media can also be a powerful tool for good. Some, but not all, media outlets have worked hard to address misinformation. Linda also praised the Science Media Centre, which has done more than any other organisation to help achieve more balanced, evidence based coverage on both Covid-19 and vaping.
Finally, Linda talked about the importance of building consensus. In the UK this has been built on vaping, with key organisations acknowledging it less harmful than smoking. We still need to work on this with Covid-19.
Linda concluded with some of the things she had learnt from working on both topics:
Finally, humour is important, and you can find a lighter take on science on Linda Bauld’s podcast Naked and Bauld on The Naked Scientists.
Session 6: Panel Discussion and Q&A
Prof Ann McNeill, Cliff Douglas, Prof Robin J. Mermelstein, Andrea Crossfield, Colin Mendelsohn, Prof Linda Bauld, OBE
Why do physicians believe nicotine cause cancers, CV disease and COPD?
Colin said that, in Australia, doctors' negative views reflect what they see in most sources. They are just not interested in assessing the risk in the detail needed. After all, they have a lot of issues to consider, and there just isn’t the time to go deep into every one of them. They also associate nicotine with smoking, and they receive very little training on nicotine.
Cliff said that national groups in the US can serve as educators. But some of these groups are helping the anti-vaping campaign. They ignore harm reduction, and the needs of tens of millions of smokers. They need to step forward and play a real role.
On being accused of ‘being in bed’ with the tobacco industry...
Cliff said there is a degree of censorship, or inferred censorship [when it comes to vaping], where people are afraid. Young researchers who are seeking tenure are concerned that if they wade into this area they may get into trouble and that it will impede their scientific advancement. At the University of Michigan, Cliff is hammering home the point that independent, talented researchers who make findings that support harm reduction are in no way supporting the tobacco industry or serving as their mouthpiece.
On changing perspectives on vaping:
Andrea said that in 2013 she had concerns about young people vaping and the gateway effect. Her perspective has evolved after seeing the evidence build year on year both in the UK and locally, and seeing smoking rates reduce in young people. It’s still important to understand some people’s continuing hesitation, to understand where they are and have those difficult conversations.
Linda said there were two key things for her. The first was hearing vapers' stories, and having more contact with them. The other thing is a building consensus. A shared view is very powerful and reassuring.
Listening to the videos this year, I was reminded of the first summit. Back then, medicalisation (read: ban) seemed likely, and key organisations (including ASH UK and the MHRA) were very unsure about the devices.
By bringing these people and organisations into direct contact with the very people doing the actual research into vaping, the E-Cig Summit helped change the course of vaping in this country. Today, at least in the UK, the situation is very different. As Linda Bauld pointed out, the UK is building a consensus around vaping, a consensus that has shown resistance to the deluge of junk science flooding in from the USA and amplified by the media.
In many parts of the world it is a different story. Indeed, regulator meddling, foundation money and vested interests mean many people who would have switched to vaping still smoke - with half likely to experience an early death because of it. But as for the long run, Dr Etter’s quote from the 2013 Summit reverberates round my head - “You can not stop a tsunami with a law”.