Category: opinion

  • Vapor Voice Exclusive: Rotting Your Boots

    Vapor Voice Exclusive: Rotting Your Boots

    Credit: Hutpaza

    Vaping opinions may vary depending on a person’s experience and knowledge.

    By George Gay

    On Aug. 24, The Guardian, the daily newspaper to which I subscribe, ran an opinion piece about nicotine pouches and vaping devices in its Journal section, which carries its leaders, opinions, letters, birthdays and obituaries. I much enjoy reading this section, in which the letters are often informative and the birthdays throw up some oddities.

    The famous people listed as having birthdays on the day of the paper are always briefly described in relation to the jobs or activities in which they are involved or, in some cases, the jobs or activities in which they were once involved. For instance, politicians who are no longer active in politics might be referred to as former Members of Parliament, but the “former” label is not usually applied to sportspeople, and this can lead to some amusing results.

    A person celebrating their 60th birthday, for instance, might be described simply as a javelin thrower, but the most impressive birthday announcement I have seen was in an April 2022 paper in which a 91-year-old man was described as a rugby player. Respect.

    The Journal always bears as part of its masthead the assertion that “comment is free … but facts are sacred,” a lofty statement that seems not always to be lived up to, especially when the subject is tobacco or nicotine, subjects about which the paper is po-faced in the extreme and often ill-informed.

    The opinion piece on Aug. 24 told how the writer, a vaper, faced with a six-hour rail journey during which she would not be able to vape, decided to buy some nicotine pouches in the hope that they would make the trip more palatable, even though she had not previously indulged in such products.

    On boarding her train, she placed a pouch in her mouth, but, after 15 minutes, had thrown the entire pack, and presumably the pouch she had experimented with, in the bin. Apparently, she spent the rest of her journey, five hours and 45 minutes, feeling nauseous but not throwing up on the table in front of her. Respect.

    This outcome was somewhat surprising since she also wrote that she had lived for some time in Sweden, where she had come across snus but not used it because she had been warned by friends that first-time users usually were made to feel ill. At this point, I thought the opinion might examine the need for nicotine pouch packs to provide information about how best to start using this product, perhaps suggesting only very limited exposure in the beginning.

    In fact, as I understand it, some products do carry such information in countries where the consumption of oral products is not already established and where the provision of such labeling is permitted.

    Perhaps there might have been a discussion on whether there should be available beginners’ packs with pouches that offer only slow, low-level nicotine deliveries. Such a discussion could then have looked at the ethical issue of offering pouches that might be seen by some as being aimed at people who were not already tobacco or nicotine users.

    It might have been interesting to look, also, at whether, to overcome this issue, all nicotine pouch packs might offer a range of nicotine deliveries. After all, perhaps even long-term users might like to have a low-hit product now and again.

    But no, the writer, Imogen West-Knights, had other ideas. She apparently started thinking about “nicotine and addiction in general.” Although West-Knights did not define what she meant by “addiction,” she had already declared that she was “pathetically addicted” to nicotine and her vape, and later wrote in two instances of nicotine as being “mind-warpingly” addictive.

    She was interested in what she said was a moral quandary thrown up by the question of whether it was “… bad for people to have access to a mind-warpingly addictive substance if it has no health consequences?” In the end, she took a libertarian stance and declared that what others did was none of her business nor that of the government.

    To my way of thinking, she came to the correct conclusion, but she could have saved herself a lot of anguish in respect of nicotine if she had taken the trouble firstly to define addiction. In writing that nicotine had no negative health consequences, she was, in effect, declaring that nicotine was not addictive.

    To be addictive, a product or an activity must be indulged in compulsively, and that activity must have negative health consequences, otherwise, breathing unpolluted air, if such were available, would constitute an addiction.

    I wrote a letter to the newspaper pointing this out, but it didn’t cut any ice. Obviously, what was written came under the “comment is free” part of the declaration, not the “our opposition to tobacco and nicotine is sacred” part.

    I don’t blame West-Knights for her confusion because she had apparently looked up the U.K. National Health Service’s Quit Smoking webpage and found that it stated that “although nicotine is addictive, it is relatively harmless.”

    In other words, the NHS had squeezed nicotine into the addictive category simply by inserting the phrase “relatively harmless.” But, of course, such a fudge raises its own issues because it clearly drags into the addictive sphere all sorts of other products and activities. Indeed, the writer raised the cases of coffee and sugar.

    Which leads me onto another addictive product, water. If, as above, addiction is taken to be the compulsive consumption of a substance or involvement in an activity that causes harm to the consumer or participant, then, apparently, both cigarettes and water are addictive. This came to my notice when reading in The London Review of Books a review by Steven Shapin of a book by Christy Spackman, The Taste of Water: Sensory Perception and the Making of an Industrialized Beverage.

    Shapin made the point that there was a suspicion, if not yet solid evidence, that the toxic pollutants in water posed risks to human health that took in cancer, damage to the nervous system, liver and kidneys, and interference with fertility and development. Sound familiar?

    And there is another parallel. “It is thought that the monetary scale of American lawsuits against companies responsible for PFAS [perfluorinated and polyfluorinated alkyl substances] water pollution may eventually dwarf those involving asbestos and tobacco, considering that people are in a position to decide whether or not to smoke cigarettes, but everybody has to drink water,” Shapin wrote.

    He made the point too that there are potentially dangerous things in water that are difficult for the consumer to detect because they don’t taste, smell or look odd. He didn’t contrast water and tobacco in this instance, but it is the case that cigarette smoke doesn’t sneak up on you in this way because it has a particular smell and is highly visible.

    For the sake of my health, I think it might be time to try overcoming my long-term addiction to water. My grandfather, a beer aficionado of some note, warned me on many occasions that water rotted your boots. Respect.

  • Cognitive Dissonance

    Cognitive Dissonance

    Credit: Good Ideas

    Regulators often run a campaign of hypocrisy when confronting vaping.

    By George Gay

    “However, it is vital that we do not sit and wait for this data [on the long-term health impacts of using nicotine-containing products] and action is taken now to prevent any potential harms caused by vapes.”

    “However, it is crucial that any proposed regulations [on vaping] are based on robust evidence, ensuring they are effective as possible, and implemented without delay.”

    You could be forgiven for assuming that these two quotes have been taken from statements by people or organizations on different sides of the vaping debate because, on the one hand, it is said to be “vital” that action must predate the collection of data while, on the other hand, it is said to be “crucial” that the collection of data must predate action. But you would be wrong.

    The first is from the final paragraph of the Executive Summary of the August-published report from the British Medical Association (BMA: the trade union and professional body for doctors and medical students in the U.K.) titled Taking Your Breath Away: Why We Need Stronger Regulation of Vapes. The second is taken from the final paragraph of the full report.

    Would I be rude in suggesting that the BMA authors might be suffering from cognitive dissonance and that they should try healing themselves before handing out advice willy-nilly? After all, the authors, if not doctors themselves, are representatives of the U.K.’s doctors, people whose opinions those of us of the outer dark tend to accept without question in respect of matters of health.

    And this level of trust, I think, is perfectly reasonable when it comes to face-to-face consultations involving doctors and individual patients. But once doctors become involved in wider concerns, I think it is necessary to take a more jaundiced view of what they have to say.

    Once doctors stop seeing people as individuals and view them only as groups marking points on a graph, they lose that which makes them special, as when they pay more attention to your “body mass index” than to your body. At a populations level, their pronouncements are little more than opinions based not on their medical knowledge but, as in the case of the rest of us, largely on ideologies and prejudices. They become part of the “tyranny of experts.”

    In other words, it is important to keep in mind that once doctors step outside the surgery, they can be just as irrational as you or me—or you at least; let’s keep me out of this. Indeed, some time ago, I was at an event where, at the end of the evening, a person who I knew to be a senior medical doctor was doing the rounds, pouring any remaining wine from the bottles on the tables into his glass and drinking it. The event had attracted a wide range of people, from those in their early 20s to those in their 80s, and even a few teenagers.

    Sitting at a table watching this person, I started to wonder about him. Was he, for instance, an alcoholic or somebody who usually drank in moderation but was on this occasion letting his hair down? Did he understand, care, or was he too far gone to think about the example he was setting to the younger people present?

    Surely, I thought, he must be aware that any level of alcohol consumption creates health risks. Was he a hypocrite who would have been offended if I had smoked or vaped in front of the young people; was he dimmer than his qualifications would have me believe; or was he as heavily into cognitive dissonance as he seemed to be into drinking?

    I often think of this occasion when I read of medical professionals making pronouncements on smoking and vaping (but rarely on drinking). And I thought of it again when I read the BMA report, which should have been called the “however” report. You might have noticed that the two report quotes with which I started this piece both opened with the word “however.”

    Basically, the report could be summed up as one that reluctantly admits the important role that vapes can play in helping smokers quit their habit but then de facto goes on to say, “however,” we don’t like these products and therefore we are calling for them to be debased by regulation to the point where they will not appeal to anybody and smokers will return to smoking. After all, you know where you are with smoking because people have been doing it for a long time.

    The word “however” appears 16 times in the BMA report, whose text takes up only 12 pages. How many times have we seen doctors and researchers put their names to such “however” reports? Reports that purportedly aim at striking a balance between the need to keep vapes appealing enough to smokers so that they are encouraged to give up smoking while not appealing to young people but that, “however,” always come down in support of protecting from themselves a few misbehaving students from well-off families at the expense of trying to help financially impoverished smokers?

    Reports that complain about how smoking is the major cause of premature death worldwide but wind up unable to support the use of the one product that has come along that could make a real dent in the toll caused by smoking because the authors are ideologically opposed to people enjoying using nicotine.

    The authors of such reports like to sex them up by talking of an “epidemic” of vaping that is in part harming “children.” You can imagine them wringing their hands in anguish at what is happening to these middle-class, mischievous students while ignoring the fact that hundreds of thousands of children from financially impoverished families live in poverty, meaning they are undernourished, with all the negative impacts on their life chances that that entails.

    On Dec. 22, just three days before the major feast of Christmas, The Guardian newspaper led with a story titled “Revealed: huge rise in hospital admissions with malnutrition” while on page six it ran with “‘Heartbreaking’: Teachers tell of children with bowed legs and no winter coat.” The latter story, by Jessica Murray, quoted a headteacher as saying some children at her school had bowed legs because they were so deficient in vitamins.

    “We’ve had children so malnourished they’ve had heart murmurs,” the headteacher said. “It’s heartbreaking. It’s not how it should be. It’s the worst I’ve ever seen it. We’ve got two-year-olds coming in and trying to eat sand because they’re so hungry.”

    As the lead story pointed out, such deficiencies can interfere with brain and bone development and cause health problems in later life. But, despite this, there has been little follow-up of these issues since then, with space being given over rather to numerous negative stories about vaping. 

    The BMA reports on health problems visited on children by vaping but set against the damage caused by malnutrition (or any number of other causes, such as ketamine addiction), these problems are minuscule. “The NHS revealed that in 2023, 50 children were admitted to hospital with vaping-related disorders,” the report states “The U.K. has a population of more than 12 million children defined as those 0 years old to 17 years old, so 50 represents 0.0004 percent].

    “This is up from just 11 children three years previously, demonstrating the significant growth in prevalence of vaping in this age group. Vaping-related disorders can range from lung damage to worsening asthma symptoms, which include wheezing, coughing and chest tightness.”

    These numbers are tiny, and, in any case, I wonder if even they can be put down to vaping in the way that malnutrition can be put down to vitamin deficiencies. After all, we are not told how many of the children said to be suffering from the effects of vaping live in our highly polluted cities and/or in the many houses afflicted with damp and mold that are inhabited by impoverished families, but perhaps the doctors assumed that vaping children would live in comfortable houses in leafy suburbs.

    In any case, I don’t wish to sound cynical, but aren’t children suffering from asthma rather asking for trouble if they vape? After all, children who are intolerant or allergic to certain foods are taught to avoid them. We don’t seek to regulate such foods so they become unpalatable to children and adults alike.

    Why is there so much emphasis on children vaping but so little on their going hungry? There are a number of reasons, but, in my opinion, the main one has to do with the fact that coming down on vapers and smokers allows those involved to do some virtue signaling at little or no cost whereas making sure that children are properly fed needs an effort by those responsible that comes with a price tag that most are not willing to pay.

    In fact, the BMA’s report came out at a rather bad time in respect of its attitude to at least some children. The day after publication, The Guardian newspaper ran a story under the heading “BMA accused of witch hunt after transgender care leak.”

    The piece, by health policy editor Denis Campbell, described how the BMA had been heavily criticized by key medical figures since it voted on July 17 for, in effect, rejecting a report by Hilary Cass on transgender care, which put it in the position of being the only medical organization in the U.K. not to accept, and to find fault with, her findings, findings that were accepted by the previous right-of-center government and its left-of-center successor.

    Campbell wrote that the Academy of Medical Royal Colleges, which represents all U.K. doctors professionally, had criticized the BMA’s refusal to accept “the validity of the evidence and consequently the findings of the independent Cass review of gender identity services for children and young people.”

    And ignoring the rule that when in a hole, the best idea is to stop digging, the BMA allegedly undertook a “witch hunt” to try to identify which senior figure leaked that it was set to oppose the Cass review. According to Campbell, critics described the BMA’s action in this regard as “disgraceful” and “Orwellian.”

    None of this will make the slightest difference, of course. Nor will the fact that, in my opinion, the BMA report is largely a rehash of stuff that has gone before many times over because the likelihood is that the government, like the general media, will merely read and relay the recommendations, not the thinking or lack of thinking behind them. They will probably not notice that though the report’s 99 references suggest a scientific accountability, in places it reads more like an essay in that it throws out unreferenced and vague statements such as “there are concerns that,” “there is no doubt,” “many health organizations” and “can also influence belief.”

    Some of what is said seems not to be supported by evidence and amounts to little more than urban myths while some is based on the lazy idea that what happens in the future will be the same as or similar to what happened in the past unless an intervention is made.

    And how does the BMA come up with a sentence such as this: “Novel products such as nicotine pouches are a growing class of noncombustible nicotine product that pose similar public health risks as [those posed by] vapes yet are not sufficiently regulated.” One would have hoped that doctors or their representatives would have figured out that the risks must be different. One activity involves inhalation while the other does not.

    The BMA report, like many such reports in the past, comes with a helping of emotional blackmail. The word “children” is used 55 times, and the phrase “young people” is used 23 times, but while these are not used as synonyms (on 16 occasions on which each of these terms are used, they are used in combination as “children and young people”), we are not told what the difference is between them, so we can assume only that “young people” refers to those people who are 18 years of age or older but who are not middle-aged or old. The word “youth” is used 15 times and the word “adolescent” four times.

    We are also treated to “people under 18” (the usual definition of a child in the U.K., though the National Health Service sometimes refers to children as those under 16), “children 11–17,” “young fashionable models” and even the impersonal “younger market.”

    And what of the “growing epidemic” mentioned in the first sentence of the Executive Summary? Well, this is what is said in the rest of the first paragraph: “Vape use by adults has risen significantly over recent years, but more worryingly, by children and young people. 7.6 percent of 11[-year-olds to] 17-year-olds are now vaping, either regularly or occasionally, compared to 1.3 percent in 2014.”

    I’m reluctant to go to bat against the BMA on the question of an “epidemic,” but what the hey? If the “epidemic” is supposed to refer to children as well as to adults (it’s unclear), under 8 percent seems a little short of a “widespread” outbreak, which is how my dictionary in part defines an epidemic. And this is especially so when you start to pull apart that 7.6 percent figure, which is from Action on Smoking and Health (ASH).

    It is made up of 4.6 percent of “regular” vapers, who, inexplicably, in my view,* are defined as those vaping more than once a week, and 3.1 percent of occasional vapers, defined as those who vape “less than once a week,” which means, I assume, they could vape only once a month, once a year or once a millennium. (*Imagine the reaction of your doctor when, on asking you whether you had regular bowel movements, you said, “Oh yes, more than once a week!”) 

    The truth of the matter is that, as part of this “epidemic,” “ever vaping” (a category it is safe to assume includes even those children who once looked sideways at a vape) fell between 2023 and 2024 in respect of all age groups examined. Of course, this is true only if the figures are correct. I guess the ASH figures are based on “self-reporting,” and it often puzzles me how those collecting data will accept the word of people, some of whom are breaking rules.

    The report seems to me to be poorly written. Take this sentence from the Executive Summary: “The availability of disposable vapes is clearly linked to the sharp rise in child use.” It seems that the BMA is mixing up cause and effect. According to it, the rise in the use of disposable vapes by children has caused the availability of disposable vapes. Well, not caused, because it clearly cannot state that, so it uses the word “linked,” which it hopes will do the same job as “cause” in the minds of the readers. Like I can say my bed is linked to my sleeping, and my knife and fork are linked to my eating.

    This linking business seems to be linked to an ASH graph that appears under the title “Rapid rise in youth vaping 2021–2023 associated with [not linked to, but associated with] growth in use of disposables.” But the graph seems to show nothing of the sort. Rather, as a subheading indicates, it graphs the “Proportion of vapers of all ages who mainly use disposable vapes, by age.” And the BMA does not mention that between 2023 and 2024, the proportion of 11-year-old to 17-year-old vapers who mainly used disposable vapes fell from 69 percent to 54 percent.

    This might come as a surprise, but I am on the same page as the BMA when it comes to one issue: the need, from an environmental perspective, to ban disposable vapes. Companies and consumers have proved time and time again that they are unwilling or unable to dispose of these and other consumer products and their packagings in a manner that does the minimum damage to the environment. They, like much of the rest of the population, seem to be so dim that they cannot absorb the simple but vital environmental message so eloquently expressed about another matter in the film Moonstruck: Don’t shit where you eat.

    Where I diverge from the BMA’s stance is at the point at which it is not willing to accept those products that have been designed by parts of the vaping industry to address these environmental concerns while still offering the positive usage characteristics of disposables.

    In fact, the report’s first recommendation is that the U.K. government bans “the manufacture for commercial sale and the commercial sale of all disposable vapes ….” I’m not sure how far the BMA imagines the U.K. government’s writ runs in such matters, but I would assume that at least a number of China-based manufacturers would be somewhat bemused by such an idea.

    But the BMA, while it is ready with its vaping advice, seems to be rather lost when it comes to the world of vaping. It bemoans the fact that the “nicotine contained in one disposable vape can be equal to [that in] two packs of cigarettes.”

    What is the problem here? It is not the quantity of nicotine in a device that counts but the amount of nicotine delivered to the user, and the amount of nicotine delivered is controlled by the vaper. And surely, if the BMA were really concerned about the environmental consequences of disposables, it would welcome bigger nicotine reservoirs.

    Bizarrely, the BMA also talks of vapes not containing tar. Well, no, but then neither do cigarettes; the tar is a product of the combustion process after a cigarette’s tobacco is set alight. And there is no tobacco in a vape and no combustion process.

    And finally, the BMA notes that “[a]s more young people are using disposable vapes and using them more frequently, there are concerns that they are at significant risk of addiction to nicotine.” Here the risk is probably being exaggerated. According to ASH figures, more 11-year-olds to 17-year-olds (9.5 percent) try vaping only once or twice than go on to become either regular or occasional users (7.6 percent), and 1.3 percent are classed as having been vapers but having quit.

    The question should at least be asked about how this 1.3 percent threw off this appalling addiction. Perhaps they returned to smoking, or did they just get bored with vaping? Young people get bored with things quite easily. That’s the main difference between old people and young folk. The former hang onto the past with a vice-like grip because they cannot compete in the present while the latter want to move on; they are hungry for the future. You can see this reflected in the charts of ASH and the dark forebodings of the BMA that are issued even as the young are moving on, beyond last year’s concerns.

    The report’s second recommendation and the one that has attracted most criticism calls for a ban on all nontobacco vape flavors. The BMA is clearly against vaping, and here at least the organization nails its colors to the mast but not without hitting its thumb in the process.

    Look at this sentence from the report, bearing in mind that the report is supposed to be a serious attempt at influencing government policy and presumably was read by any number of people before being loosed on the world: “However, like children, fruit flavors are the most popular with adults.” Hmm.

    Recommendation three, if implemented, would degrade the aesthetics of vaping devices and their packaging, which would make them less appealing to smokers, a move that would be simply vindictive since the BMA also wants, according to recommendation four, for these products to be kept out of sight at retailers.

    And just in case there were any doubt that the BMA is against vaping full stop, part of recommendation five calls for a government-funded and government-delivered “education campaign”—read propaganda—to warn the public “on the dangers of vapes to reduce appeal.” Again, an awful phrase, but we can figure out what is meant.

    Recommendation five includes some sensible ideas about policing the retail environment, but these are measures that the industry, at least in the form of the U.K. Vaping Industry Association, has been calling for for years. In fact, the recommendations do not go as far as the UKVIA has suggested, though there are signs that the government might be starting to favor the suggestion about licensing retailers that sell vapes.

    This is sensible. Most of the problems that vaping throws up have been caused by 14-years-and-counting of austerity under which the authorities responsible for overseeing retailing have been starved of funds so that checking the import, compliance and retail sale of these products has been nowhere near as vigorous as it should have been.

    But somehow, it is the smoker and the vaper who must be punished for these failures. Children are being naughty in using these products, manufacturers are putting noncompliant products on the market, retailers are selling vapes illegally, the authorities are failing in their duty to stop this abuse, but it is the people who are not doing anything wrong, the smokers and vapers, who are to be made to suffer.

    Recommendation six merely expands the report’s ideas, if you can call them that, to other nicotine products but not to traditional tobacco products.

    I think that one of the problems identified above is that the opinions of doctors should not be given too much credence when they are based on issues that go beyond their individual patients. We know that a lot of medical doctors still believe erroneously that nicotine causes cancer.

    And in a letter to The Guardian at the beginning of September in response to a government proposal to ban smoking in beer gardens, James Scott wrote, in part, “Tobacco is unique among the substances that humans use: When used exactly as intended by the manufacturer, it will harm and eventually kill its consumers. It is categorically different from alcohol and other drugs humans use and needs to be treated as such.”

    This completely ignores recent findings that drinking alcohol also harms and eventually kills its consumers when used exactly as intended. Writing in The Guardian on Aug. 21, Devi Shridhar, chair of global public health at the University of Edinburgh, pointed out that the World Health Organization had stated in January 2023 that there was no safe level of drinking. “The agency highlighted that alcohol causes at least seven types of cancer and that ethanol (alcohol) directly causes cancer when our cells break it down,” Sridhar wrote.

    But of course, it goes so much further than the direct harm caused by consumption. Smokers, unlike drinkers, do not go home and assault their partners just because they have been smoking. They do not start fights in the street just because they have been smoking, and they do not cause vehicle “accidents” just because they have been smoking.

    The problem is that you must have a wide view of society to see things clearly, in the round. On the same day that Scott’s letter was published about the proposed ban on smoking in beer gardens, there was a letter from Robert Lee, the contents of which anybody who has been involved in magistrate court proceedings would recognize as being right on the money.

    “The government’s almost evangelical crackdown on smoking contrasts sharply with its attitude to alcohol, which is responsible for more problems,” Lee wrote. “I sat as a magistrate for many years, and a huge proportion of offenses were directly or indirectly linked to alcohol. But I never heard a defense lawyer plead in mitigation that their client had smoked too many cigarettes.”

    And I cannot imagine that excessive vaping will ever be cited as mitigation in such proceedings. There is only one reason why smoking tobacco and vaping nicotine are under constant attack by all and sundry while drinking ethanol is not, and that is because the U.K. runs on hypocrisy. Let them eat sand.

  • ‘Vaping Innovation Just Getting Started’: Hon Lik

    ‘Vaping Innovation Just Getting Started’: Hon Lik

    Hon Lik (Photo: Imperial Tobacco)

    Hon Lik, the inventor of the modern e-cigarette, spoke with Imperial Brands about the vaping category, the challenges it faces and his hopes for the future of tobacco harm reduction.

    Lik said that he’s “satisfied and gratified to witness this revolution [vaping] that’s changing the lifestyle of millions of adult smokers around the world.”

    “I truly believe the innovation has only just started,” he said.

    “In the coming decades, with the help of long-term epidemiological data, I think it will be revealed that NGP [next-generation products] like vapes are clearly harm reduced compared to combustible tobacco—hopefully creating a pathway for tens of millions more smokers to leave cigarettes behind.”

    The full interview is available on Imperial Brands’ website.

  • Burton: Menthol Marketing Orders a ‘Significant Step’

    Burton: Menthol Marketing Orders a ‘Significant Step’

    By Robert Burton

    Vapes are a powerful tool for adult smokers making the transition from cigarettes to reduced-risk products (RRP). The category is governed by market-specific regulation, often influencing public perception and, therefore, uptake.

    Last week, following an extensive scientific review, the U.S. Food and Drug Administration authorized the marketing of four menthol-flavored e-cigarette products for Altria-owned vaping company Njoy. This is a watershed moment for the sector and one which will have a huge and significant impact on the global RRP market.

    This announcement signifies the FDA’s acknowledgment that menthol vaping products have the potential to be an important and effective tool for adult smokers looking for reduced-risk alternatives. This is significant for the wider sector in a number of ways; above all, it sets a precedent for other markets, paving the way for other regulators, particularly those looking at bans, to consider flavors in the context of public health.

    Across the globe, we are seeing an increasing number of markets introduce bans on flavors on a precautionary basis in a bid to mitigate youth uptake. At Plxsur, we have long advocated against the ban of flavors on vape products, arguing that it has the potential to negatively impact those making the transition from conventional cigarettes, who often are drawn to vapes for their flavor, amongst other factors such as price and convenience. There are also arguments and emerging evidence that flavor bans drive the black market sale of unregulated, dangerous products.

    There will be many that, understandably, say this decision is “too little, too late,” but it is nonetheless encouraging to see the FDA, with its extensive science and evidence-based review, validating that with effective regulation and enforcement, flavored vape products are “in the interest of public health.” Those countries that have considered flavor bans should look to the U.S. and conclude that it can’t be justified from a scientific review perspective.

    While this is the first authorization of a “characterizing flavor” by the FDA for vaping products, two of the major regulatory influencing bodies, the FDA and the Medicines and Healthcare Products Regulatory Agency (MHRA), now acknowledge that there is value in non-tobacco-flavored vaping products.

    This decision has the potential to impact the world. The U.S. has long influenced international markets, so it sets a benchmark that we expect other, less vape-supportive governments and regulatory bodies will follow.  

    Rob Burton

    In Italy, tobacco-flavored vapes constitute 40% of the vape market, while menthol represents 21%.[1] This demonstrates the significance of flavored products in the market as a whole. If such flavors were to be banned, this would act as a barrier for smokers to move to reduced-risk alternatives and potentially lead vapers to return to cigarettes.

    In some geographies, it is great to see that vapes are being accepted as an effective alternative to conventional cigarettes, even this week’s news from Australia announcing that vapes – which until now have only been available through prescription – will soon be available for sale within pharmacies without the need for a prescription, offering an effective pathway to end the smoking epidemic in the country.

    As we anticipate the potential revision of the Tobacco Product Directive Review next year, the justification for banning flavors, from a scientific point of view, simply isn’t there. In the case of Njoy, this has been shown through closed-system pod-based devices, which offer a more cost-effective avenue for existing smokers and disposable systems while incorporating child lock systems that will restrict access to children, as is already applied by a Plxsur company, ProVape, in its SALT and KUBIK brands.

    While the FDA’s authorization is specific to these four products made and sold by Njoy and does not apply to any other menthol-flavored e-cigarettes, our expectation is this will open a channel for other such products to achieve authorization by providing the necessary framework and the potential for knowledge-sharing and guidance. With the weight of data-led evidence, the category can advocate for the democratization of this framework, enabling further regulatory authorizations for products produced by responsible vaping companies in the interest of the adult smoker.  

    At Plxsur, we have a clear purpose – to facilitate adult smokers to make positive health decisions by transitioning away from cigarettes to reduced-risk products. Flavor is a key factor in supporting smokers moving completely to such alternatives, and we look forward to seeing a more science and data-led approach being adopted across all markets as we work to save the lives of those impacted by smoking, mitigate the risk of youth uptake, and do so sustainably and responsibly.

    We view this FDA decision as a significant step forward in broadening the pathway for adult smokers, and previously lacking “off-ramp” for U.S. menthol smokers looking to make the switch, which, according to Public Health England, is 95% less harmful and, therefore, undeniably, “in the interest of public health.”[2]

    Robert Burton is Group Scientific and Regulatory director for Plxsur.

    [1] The Global Vaping Market: A Plxsur Snapshot

    [2] E-cigarettes: an evidence update: A report commissioned by Public Health England

  • James Murphy Makes a Case for Consensus

    James Murphy Makes a Case for Consensus

    Photo: pavelkant

    A global alignment on health policy is necessary to make a smokeless world a reality.

    By James Murphy

    With renewed attention on smoking and vaping regulation around the world, now is the time for action that will realize global smoke-free ambitions and ensure cigarettes become a thing of the past.

    Achieving this vision requires a global consensus on the most effective approach to create sustained and lasting changes to consumer behavior—tobacco harm reduction (THR).

    THR is one the greatest public health opportunities today, representing a pathway for hundreds of millions of smokers who would not otherwise quit to transition from combustible tobacco products to smokeless alternatives.

    Countries that have recognized the opportunity THR presents, and which have adopted supportive policies, have seen striking success in reducing their smoking rates. The U.S., U.K. and Japan are all currently witnessing their lowest smoking rates on record while Sweden is on track to declare themselves smoke-free this year—defined as having less than 5 percent daily smokers in the population—16 years ahead of the 2040 EU target.

    These remarkable transformations have been driven by widespread THR acceptance from policymakers, regulators, health officials and consumers in these markets, enabling and encouraging smokers to migrate from combustible tobacco products such as cigarettes to vapor, oral nicotine pouches, snus and heated-tobacco or herbal products.

    The widespread accessibility of smokeless products is essential for the success of THR. However, at present, this is being hamstrung by many countries limiting access to these alternative tobacco and nicotine products. For example, 60 percent of the world’s population live in just 15 countries. Of these, only about 40 percent permit the sale of smokeless products, leaving millions who would otherwise continue to smoke without the option to switch to such alternatives.

    In order to fully realize the public health potential of THR and significantly reduce the more than 8 million deaths attributed to smoking cigarettes each year, regulators around the world should embrace evidence-based science to drive positive public health outcomes. This means implementing a supportive regulatory framework that encourages adult smokers who would otherwise continue to smoke to switch while also protecting consumers with stringent safety standards and preventing underage use.

    In addition, the global success of THR depends on governments and regulators correcting persistent misperceptions of smokeless products compared to cigarettes.

    A University College London-led study published earlier this year highlighted that most smokers in England wrongly believe vaping is at “least as harmful as smoking,” with 57 percent of respondents saying they thought vaping was “equally” or “more harmful.” This echoes trends reported in the U.S., with research showing that perceptions of e-cigarettes as more harmful than cigarettes doubled year on year between 2018 and 2020. Not only are these misperceptions flawed, but they also have significant implications for public health by actively discouraging smokers who would otherwise continue to smoke from making the switch to smokeless products.

    Greater efforts are needed to counter these misperceptions—something that BAT is trying to tackle. As the world’s largest vapor company and a leader in smokeless products, BAT is committed to producing innovative products backed by world-class science and industry-leading product safety and quality standards. BAT’s THR approach is based on the growing body of research and weight of evidence approach that substantiates its belief of the reduced-risk profile of these products compared to cigarettes, which have been accepted by many international public health bodies. BAT publishes its science research to increase understanding of THR and raise awareness with stakeholders.

    Indeed, the industry developing and producing these products has a critical role to play. But to achieve the conditions required to make a success of THR, an inclusive, open and honest dialogue with all stakeholders is required. That includes policymakers, regulators and the healthcare and medical communities. Unfortunately, this is not yet the case, with the industry all too often excluded.

    We have an opportunity to usher in a new smokeless world, grounded in scientific research and a firm commitment to public health. The solutions are available today. All that is required is for the relevant stakeholders to actively work together to prioritize THR and the well-being of millions of people worldwide.

    James Murphy is the director of research and science at BAT.
  • World Medical Association Applauds WHO Anti-Vape View

    World Medical Association Applauds WHO Anti-Vape View

    The World Medical Association (WMA) has joined the World Health Organization (WHO) in warning about the dangers of electronic cigarettes and other electronic nicotine delivery systems (ENDS).

    “This warning comes amidst rising global popularity of e-cigarettes, particularly among young people, and a lack of adequate regulation in many countries,” a press release states.

    The Italian publication Formiche recently published a report raising concerns about the WHO’s tobacco control policies and strategies in combating smoking-related diseases.

    Titled, “Framework Convention on Tobacco Control: Challenges and Prospects for WHO,” the report provides a comprehensive overview of the smoking crisis, the limitations of current tobacco control policies, and the role of harm reduction and non-combustion products. Additionally, it emphasizes the need for innovative strategies and a re-evaluation of the WHO’s approach to effectively combat the global smoking epidemic.

    The report highlights how the FCTC has not considered harm reduction efforts which led to a deviation from the original stance of the WHO. Despite the FCTC’s efforts, the number of smokers have remained stable over the last 20 years, with the decrease in smoking rates being countered by the effects of population growth.

    Lujain Alqodmani, president of the WMA, said there is an urgent need for government action to safeguard children and adolescents, and the WMA supports the WHO’s efforts to eliminate nicotine products. She highlighted the “alarming situation” reported by the WHO, where 88 countries have no minimum age restriction for purchasing e-cigarettes, and 74 countries lack regulations for these harmful products.

    The Formiche report’s author also worries about the tobacco control policies pursued by many low- and middle-income countries, which are home to 18 percent of the world’s smokers and where policies either ban alternative nicotine solutions entirely or treat them like cigarettes.

    The effect of these approaches, according to the report, is that smokers who do not quit are not supported in changing to options that could present less risk to them. “The hope is that the forthcoming Conference of the Parties can represent an opportunity for public health but also, in the spirit of the United Nations, a moment of confrontation to guide policy choices based on established scientific evidence,” the report states.

  • FDA Gives Most Warning Letters to Small Companies

    FDA Gives Most Warning Letters to Small Companies

    Photo: Postmodern Studio

    Current U.S. Food and Drug Administration oversight of the vaping industry in the U.S. is likely to have minimal impact, suggests an analysis of the regulator’s warning letters for marketing violations, published online in the journal Tobacco Control.

    The regulator is failing to target the key players or the products most popular with young people, the analysis suggests, with over 90 percent of warnings sent to small online retailers rather than leading tobacco companies, and a focus on refillable devices.

    While the prevalence of vaping among U.S. adults remains low, at just under 4 percent in 2020, it is four times higher among young people.

    In 2016, the FDA announced plans to regulate the vaping industry, including a requirement for the manufacturers of e-cigarettes to obtain premarket approval (PMTA) to ensure that their products protect public health.

    In 2017, the regulator began sending warning letters to manufacturers, retailers and distributors for potential violations, such as advertising to young people, selling to minors, packaging or labeling that contravened regulations, and failure to apply for a PMTA.

    But little is known about who received these letters, the types of product they concerned, or details of the violations and their consequences.

    To try and find out, researchers from Truth Initiative assessed the content and recipients of publicly available FDA warning letters issued in 2020 and 2021. In total, the FDA issued 303 warnings: 126 in 2020 and 177 up to Sept. 9, 2021.

    The analysis revealed that in 2021, over 98 percent of all the targeted companies fulfilled all three roles (manufacturer, distributor and retailer).

    But nearly all the letters (97 percent) were sent to small online retailers, none of which were large companies with measurable market share, as evidenced by sales data.

    Companies were cited for between one and three infractions. Most involved failure to obtain a PMTA. In 2020 and 2021, respectively, 56 percent and 99 percent-plus of the infractions concerned a PMTA violation.

    And more than 90 percent of the products cited—880 different ones in total—were flavored refillable e-cigarette liquids rather than the disposable vaping devices that the evidence indicates are most popular with young people.

    Penalties ranged in severity from product detention to product seizure and fines. But loss of tobacco distributor license and criminal charges appeared less frequently in both years than these other consequences.

    At the time of the review, most (72 percent) of the websites cited for 2020 infractions were still operating as were 29 percent of websites cited for 2021 infractions.

    And as the authors note, it was impossible to find out how the targeted companies responded and whether the FDA followed through with the consequences cited in the warning letters because that information isn’t publicly available.

    “While current research estimates that online sales comprise around one-third of the marketplace, data tell us that most young people get their products from friends (32.3 percent), buy them from another person (21.5 percent) or purchase from a vape shop (22.2 percent),” the authors noted in a statement.

    “Prioritizing the products most accessed by youth, which are made available from a variety of sources, will be important to curb youth use,” they add.

    “Strong, impactful and transparent consequences need to be in place to prevent the sale of products that violate regulations necessary in protecting the health of adult users of e-cigarettes and preventing youth use alike,” the authors added.

    “The FDA should use its enforcement powers to target the manufacturing, distribution and sellers of the tobacco products that have the greatest impact on youth and products that provide no public health benefit.”

  • Mendelsohn: Prescription-Only Vaping Policy Has Failed

    Mendelsohn: Prescription-Only Vaping Policy Has Failed

    Photo: makistock

    Australia’s prescription-only model for nicotine vaping has failed, according to Colin Mendelsohn, founding chairman of the Australian Tobacco Harm Reduction Association. Writing in Filter, he urges the country to adopt a more realistic regulatory model for nicotine products.

    In October 2021, the Australian government introduced a policy that requires nicotine vapers get a doctor’s prescription and purchase supplies exclusively from pharmacies or international online vendors.

    The regulations were intended to prevent youth vaping and to allow access for adults as a smoking-cessation aid. One year on, the policy has achieved neither of those goals, according to a report prepared by Mendelsohn.

    Instead, the rules have created a thriving illicit market for unregulated vaping products that do not comply with Australian standards. Meanwhile, vaping by adolescents has reportedly increased in Australia. With no age controls in an unregulated market, vaping products are easily accessible by teens from stores and through social media.

    Nicotine liquid should be an adult consumer product, sold from licensed retail outlets such as vape shops, convenience stores, tobacconists and general stores as it is in other countries.

    Colin Mendelsohn, founding chairman of the Australian Tobacco Harm Reduction Association

    While the prescription model has made it harder for adults legally access nicotine vapes, combustible cigarettes remain widely available.

    According to two recent surveys, between 88 to 97 percent of vapers do not have a prescription and only 2 percent of purchases are made from a pharmacy. Exposed to frequent negative messaging by Australia’s medicines regulator, the Therapeutic Goods Administration, general practitioners have been reluctant to prescribe nicotine.

    The only way forward, according to Mendelsohn, is to replace the prescription-only model with a legal and regulated retail market. “Nicotine liquid should be an adult consumer product, sold from licensed retail outlets such as vape shops, convenience stores, tobacconists and general stores as it is in other countries,” he writes. “There should be strict age verification and penalties up to loss of license for underage sales.”

  • Wordly Advice

    Wordly Advice

    Credit: Alswart

    Headlines in news stories about vaping and tobacco products are often inaccurate.

    By George Gay

    Many years ago, at one of my family’s sporadic gatherings, a then late-middle-aged family member told a story about a distant relative who, on returning from the Boer War discovered that his young son had developed a stammer. The father’s reaction, so the story went, was to take the boy up to the second floor of his house, hold him by his ankles out of the window, and tell him he would get the same treatment the next time he stammered, only with the added benefit that he would be allowed to free fall.

    The boy never stammered again, according to the storyteller, who related this incident, I think, as an example of how, sometimes, even cruel means were justified by successful outcomes. His audience, made up mostly of younger people, were clearly not of the same opinion. They stood, in open-mouthed shock, until one of them said something like: “Of course he never stammered again, the poor chap probably never spoke again.” Whether this suggestion was true, I don’t know, but it seems to me that it cannot be ruled out.

    Why did I relate the above story? Well, I was reminded of it when I saw online the following headline from a Healthline Health News story: “Low-Intensity Electric Impulses May Help Struggling Smokers Quit.” I could see a similar conversation being played out:

    Researcher at conference: “Yes, the results were amazing. We just hung these smokers out of the window on live electric wires, and they quit immediately.”

    Audience member: “And are they still tobacco-free?”

    Researcher, now somewhat cagily: “Yes … they stopped inhaling completely.”

    Audience member: “Do you mean they’re dead?”

    Researcher: “Well, yes, though we’re unsure whether the cause of death was due to the electric shock or the shock of being suspended out of the window. More research is needed.”

    I have a passion for headlines, and I am also very taken by the word “struggling” in the one above. It seems to try to suggest a certain empathy with smokers, but I’m not sure this isn’t misleading. On the other hand, struggling is a good word here because it seems to illustrate the breakdance you perform when you accidentally grab a live wire, and I can imagine the young boy struggling as his father grabbed him by the ankles—though not as he was being held out of the window.

    Credit: Vadosloginov

    Struggling is the justification, I guess, for experimenting with applying “low-intensity electric impulses” to these smokers, who have been convinced that they are victims no longer in charge of their own destinies. They have been convinced that they are addicted to smoking and that it is all but impossible to give up without the intervention of people willing to do stuff to them.

    OK, I don’t want to be unfair. I’m sure the people applying the electrodes are well meaning. The story said a new study had found that smokers receiving noninvasive low-intensity electric or magnetic impulses, also described as noninvasive brain stimulations (NIBS), were twice as likely to go without cigarettes for three months to six months as were those receiving a placebo treatment. The story added that NIBS had emerged as “a new therapeutic option for several conditions, including pain management, weight reduction, alcohol use disorder and/or depressive disorder.”

    The point here, however, is that while the management of pain and depression involves complex matters that have mostly defied the best efforts of researchers to come up with effective remedies that don’t do more harm than good, smoking is a fairly simple matter for which, in recent times, at least one effective—and, joy of joys, noninvasive—remedy has been developed.

    Individuals, companies, organizations and some governments have spent a lot of effort and time developing and improving vaping devices—and other low-risk tobacco and nicotine products—that can wean smokers off cigarettes. And with encouragement, or at least a lack of discouragement, these devices would, I’m sure, be continually improved both in their efficacy and, importantly, in respect of their environmental credentials.

    But these efforts have been hugely undermined to the point where, by the end of this year, the three most populous countries, China, India and the U.S., will have either banned vaping devices or significantly reduced their appeal. Vaping’s detractors constantly moan that one of its problems is that nobody knows what long-term effects it will have.

    However, a story can be published under a health news heading supportive of a little-tested proposed quitting method that works if at all by affecting the brain, without a hint of any concern about our not knowing what the long-term effects of such brain stimulations might be.

    The situation is bizarre.

    But now I want to digress because I always like to spend time with my most recent favorite heading, and that isn’t the one featured above. My most recent favorite heading has to be this one from the Manila Bulletin: “Thailand ready to legalize smoke-free products like the Philippines.”

    Vaping concept word cloud background

    In part, I like this heading because it speaks to a debate that crops up every time a new minister is appointed to head the U.K.’s education department: English grammar. What usually happens with a new right-leaning education minister is that she comes into her post with a demand that the English language curriculum be changed so that pupils are drilled in the (soon-to-be-forgotten) minutiae of complex grammatical rules that are, in reality, of interest only to academics and the otherwise friendless.

    On the other hand, a new left-leaning education minister will demand the curriculum be changed so that pupils are encouraged to be creative rather than necessarily grammatically correct, resulting, in extremis, in their producing highly creative but unreadable twaddle.

    What tends to get forgotten in this debate, and in most others, is that there is a middle way in which basic grammar is taught to everyone, but the more esoteric grammar is pursued only by those with a love of such things.

    To my way of thinking, the most important thing to keep in mind when writing in English is word order. But it is one of the most overlooked. Take any daily English newspaper and you are likely to see a sentence that says something like, “Joe Bloggs was yesterday sentenced to five years imprisonment in the Central Criminal Court.” Of course, this is not true. There is overcrowding in English prisons, but I don’t think anybody has put forward as a solution the idea that convicts should serve their time within the country’s courts.

    The sentence should read something like, “Joe Bloggs was yesterday sentenced in the Central Criminal Court to five years’ imprisonment.”

    And if we in England cannot get such basics right, it is unfair for me to poke fun at a heading in a publication whose journalists and editors are working in their second language. But, in my defense, the heading is funny because, to use one of the U.S. Food and Drug Administration’s favorite words, it “deems” the Philippines, a country of about 112 million people, to be a smoke-free product.

    All that is needed to make sense of the heading is to change the word order to something like, “Thailand, like the Philippines, ready to legalize smoke-free products.”Or if the subs cannot take the commas, then it can be rendered as, “Thailand to follow the Philippines and legalize smoke-free products.”

    But now I would like to digress again because, mainly, I’m more interested on this occasion in looking not at my most recent favorite heading but at my most recent least favorite heading, which appeared in Yle News: “One in three teens buys snus on social media, study finds.”

    Wow, even though the story refers to Finland, which bans sales of snus but might be thought of as being within one of the world’s major spheres of snus interest, 33.3 percent is a huge percentage of the teenage population to be buying snus on social media, especially when you consider that, despite the ban, some teenagers must be obtaining snus in other ways, and yet others must be indulging in different types of tobacco products.

    But, of course, the heading shouts out a message that is not true. When you read the body of the story, it becomes clear the heading should read, “One in three teenage snus users buys snus on social media, study finds,” which puts a different complexion on things. On this basis, there might be only three teenage snus users in Finland, one of whom buys her products on social media.

    Of course, the sub-editors wouldn’t like my suggested revisions because a couple of words have been added to the heading, which now, horror of horrors, contains the word snus twice. But in the interests of accuracy, surely it would be worthwhile running what would admittedly be a clumsy heading, or at least it would be worthwhile spending a couple of minutes getting around the problem caused by a misleading heading.

    It would be easy to get around the number-of-words problem by dropping the superfluous “study finds.” And you could cut out the snus repetition by replacing the second usage with the word “products.” Or if you wanted to go for a harder-hitting headline, you could run it as, “One in three teenage users buys snus on social media.”

    Truth matters, and unfortunately, many casual readers, I’m sure, will have taken the heading to mean what it says. And they will have gone on to have conversations with friends and family, who will have passed the story to others … no doubt in exaggerated form. To me, the heading is likely in this way to nurture a moral panic, and, in so doing, undermine a product people can use to move away from smoking and toward a far less risky future.

    The story, which was based on a School Health Promotion study, seemed to look at students widely, though the only groups specifically identified were those in grades 10–12 and vocational students. And one serious problem with the story, to my way of thinking, is that it indulges in the usual blurring of lines when it comes to references to young people, with the use, in a story of fewer than 300 words, of “children” (three mentions), “young people,” “students” (two mentions), “teens” (including in the heading, three mentions), “youths” (two mentions), “youngsters” and of course the panic-inducing “kids.”

    And to add to the moral panic, the Institute of Health and Welfare (IHW) is quoted as calling for parents to keep an eye on their children’s social media activity, adding that online platforms were making it easier for young people to buy tobacco products. It could have added, but it didn’t, that it might have been a good idea to keep an eye on what was being delivered to the family’s home.

    You have to ask yourself what exactly the problem is here. Well, according to the story, the study found that up to [my emphasis] 43 percent of students in grades 10–12 and 67 percent of vocational school students used a tobacco product at least once last year, “with snus becoming increasingly popular.” Here we have our old friend “up to,” which could mean that no grade 10–12 students used a tobacco product at least once last year.

    Of course, it seems ludicrous, too, to base a study on whether students used a tobacco product once in a year. These people are students, not saints. I bet some of them skipped class at least once last year, drank alcohol and told fibs about the reindeer eating their homework.

    And look at the tired piece about snus, ostensibly the subject of the story but simply tagged on to the end of the sentence as an unsupported afterthought: “with snus becoming increasingly popular.”

    But I think the crowning glory of the story is that, after warning specifically about young people obtaining snus on social media, it comes up with the following: “However, the most common way kids are introduced to tobacco products is through friends, the study found.”

    Of course, there was no quoting the IHW as warning parents to keep an eye on the direct interactions of young people. Perhaps that was regarded as a step too far. Having stoked moral panics over tobacco products and social media, it was thought to be unhelpful to start a moral panic over friends. 

  • Gay: Are Prescription Vapes Better Than Consumer Vapes?

    Gay: Are Prescription Vapes Better Than Consumer Vapes?

    By George Gay

    I love the following heading, which heralded a recent Taiwan News story: Over 40 percent of Taiwanese vapors unaware e-cigarettes may contain nicotine.

    I mean, if vapors have reached a level of consciousness that has allowed them to dabble in the concepts of awareness and unawareness, and to articulate, for instance, an unawareness to researchers, they need to be accorded rights. Regulators need to engage with these vapors before, for instance, removing flavors from them.

    It cannot be right to take such action without holding a consultation, difficult as that might be with what, after all, would be a somewhat ethereal interlocutor. We can only hope that if regulators fail in this duty, a good lawyer will step forward and mount what would have to be a pro bono challenge on behalf of vapors.

    I suppose I shouldn’t laugh at the heading. I often make the vapors/vapers error while typing, and it is only through the eagle eyes of my proofreader wife that these errors get corrected. But the heading struck another chord. What does it say about more than 40 percent of vapers in Taiwan, and, I assume, fairly large proportions of vapers in other places, that they happily consume something of which, to an important extent, they are ignorant? And what happens during a visit by such a vaper to one of those doctors who wrongly believes that nicotine in the amounts inhaled during vaping is dangerous? Imagine the confusing consultation if you will.

    Doctor: Ah, there you are. Come in, take a seat.

    Patient: Thank you.

    Doctor: No, no, leave it where it is, just sit on it; and for goodness’ sake, leave your clothes on.

    Patient: Sorry.

    Doctor: Now, firstly, let’s talk about your smoking.

    Patient: I don’t smoke anymore.

    Doctor: You don’t? Well done. How did you give up?

    Patient: I switched to vaping.

     

    Doctor: Dear me, that’s no good. Nicotine is dangerous and addictive.

    Patient: Vapes don’t include nicotine.

    Doctor: They don’t? Oh well, I was going to prescribe these nicotine patches, but I guess you won’t be needing them.

    Patient: But I thought you said nicotine was dangerous and addictive.

    Doctor: I did? Yes, you’re right. Excuse me, I seem to be a little confused. Perhaps I need to step outside for a smoke. Care to join me? These are really low nicotine cigarettes as “recommended” by the U.S. Food and Drug Administration.

    Patient: Is that right? Well, in that case, I don’t mind if I do.

    Doctor: By the way, how’s the back pain?

    Patient: I don’t have any since I started taking the opioids you prescribed.

    Doctor: Splendid. Do you want a drink with that?

    It makes you wonder how extensive such ignorance is in other fields and in other places. How many times do some people have to pick themselves off the floor before they realize wine contains alcohol? And how many fits of the giggling munchies do some people have to experience before they realize marijuana contains tetrahydrocannabinol … well, before they realize it contains stuff that makes you a bit silly—a bit sillier.

    In defense of the 40 percent or more of vapers, it has to be said that in most jurisdictions, vaping devices would be regulated as a consumer product and so vapers would probably assume that, like in the case of much of the food they eat, they don’t have to delve into things too deeply. In addition, the immediate effect of vaping with nicotine would be far more subtle than the effects of drinking wine or smoking marijuana, so perhaps they could be forgiven their ignorance. And, in any case, I always thought there were effects for which it would be very difficult, if not impossible, to identify a cause.

    But perhaps I was wrong, and it is always possible to get to the bottom of things. Take a look at what is my favorite heading so far this year: Study links smoking by grandfather to women’s body fat. This is not a joke—at least I don’t think it is. I guess there wasn’t room in the heading for the “s” that would have rendered the grandfather plural and taken some of the guilt off his shoulders. Poor chap; it seems so unfair. I wonder who he was?

    “Now researchers believe they have pinpointed higher body fat in females with grandfathers or great-grandfathers who began smoking before the age of 13,” said The Guardian story of Jan. 22. I’m not sure what the word “pinpointed” is supposed to mean here, but it suggests to me an accuracy of linkage (given the heading) that cannot possibly be right, especially given the equivocations of the next sentence but one (with my emphasis added). “The research suggests exposure to substances can lead to changes that may be passed through the generations, though the team [at Bristol University] say more work is needed to confirm this and understand how it may happen.’

    I’m not sure whether one of my grandfathers was a smoker (the other took snuff), because I never met him, but I guess I can work back and say probably not because none of his granddaughters or his great-granddaughters was fat. Certainly, none of his three daughters was fat, something the researchers might like to put down to the fact that the daughters’ grandfather did not smoke while young. I would suggest a more likely and direct cause was that their father was killed during WWI, and while his widow managed to feed their daughters well, there was never the sort of excess of food that would render a young person fat, leading to her being fat in later life.

    Smoking might not be good for you, but it doesn’t “kill,” and expending effort trying to trace its effects through multiple generations strikes me as a waste of time, partly because smoking is dying out. Additionally, you cannot, as far as current knowledge has it, go back in time and alter the behavior of your grandfather or great grandfather, and, given that smokers are not moved by the grotesque health warnings they are exposed to and that threaten terrible consequences being visited upon them in the near future, it seems unlikely they are going to quit because of the possibility their smoking might or might not lead to their female grandchildren or great-grandchildren becoming fat. Being shot by a sniper does kill, and the effects of such a death are immediately tragic and not hard to trace, so I think we would be better off trying to research how we can prevent pointless conflicts.

    But I digress. Let me take a look at another story, this one on the BMJ website, entitled “Should e-cigarettes be licensed as medicines?” Perversely, I was attracted to this one because I have a dislike of headings that ask questions. I mean, I don’t believe in keeping a dog and barking myself. On this occasion, however, my eye was drawn to an introduction that read, “As the U.K. announces support for medicinal licensing of e-cigarettes, Nicholas S. Hopkinson argues that this will give doctors another means to help smokers quit. But Jorgen Vestbo, Andrew Bush and Jonathan Grigg say that its benefit is unproved and that harms are likely.”*

    What I found intriguing here was the statement attributed to Vestbo, Bush and Grigg making the point that “its [medicinal licensing of e-cigarettes’] benefit is unproved.” Given that later in the piece these three, under the name of Vestbo, write, “[n]o country in the world [like there are countries not of this world] other than the U.K. has licensed e-cigarettes as drugs …,” it seems to be obvious that the benefit of medicinal licensing could not have been proved. This is especially so given that, as far as I am aware, no “e-cigarette” has been given a medical license in the U.K.

    So this is the dangerous-precedent/slippery-slope-type of thinking that, if it had been ingrained in humans from the beginning, would have meant we would never have ventured outside our caves to look for food, with the inevitable result that we would have died out. Now you possibly think that might have been no bad thing, and I would not entirely disagree with you.

    But we are where we are, and, in my view, medicinal licensing needs to be given a chance. The idea that the U.K. is to try medicinal licensing, providing manufacturers want to go down that route when other countries are not, provides a fantastic opportunity to test fully whether such a system is beneficial. The U.K. will be going head-to-head with countries that won’t introduce medical licensing; so, by comparing the results it achieves with those from otherwise “similar” countries, useful conclusions could be drawn.

    In fact, we are currently in a situation whereby, to my way of thinking, we can set the world up as a giant quit-smoking laboratory. We can study the relative performances, in whichever way is thought best, of the U.K. with its medicinal licensing of e-cigarettes and acceptance of combustible cigarettes; New Zealand with its introduction of a smoking endgame along with its acceptance of e-cigarettes; and India with its ban on e-cigarettes but not on traditional cigarettes.

    OK, I can imagine that some people might complain that what I am suggesting would raise ethical concerns to do with using people as a means to an end rather than as ends in themselves, but the “experiments” would involve only observations of what was being caused to happen, independent of the observers.

    It cannot be denied that there are potential benefits to what the U.K. is proposing. For one thing, as Hopkinson points out, medically licensed devices have the potential to be more effective than consumer devices because they can be made available in strengths greater than those permitted for consumer products.

    Additionally, Hopkinson points out, the fact that devices would go through a medical licensing process “should provide further reassurance to healthcare professionals that they can help their patients to quit smoking in this way, particularly in mental health settings where smoking rates remain high.”

    And he makes the point that the introduction of e-cigarettes that have been through a stricter medicinal licensing process is likely to improve confidence among smokers who so far have been reluctant to try this approach.

    That last point does raise a question about whether some smokers would baulk at being treated as patients in need of medical devices, but what I like overall about Hopkinson’s piece was its positive approach. There was a spring in his step such that even when he wrote of other tools being available for smoking cessation, those tools were such as to support smokers to make the switch.

    On the other hand, the piece by Vestbo, Bush and Grigg seemed to my way of thinking to be negative, though I would urge you to read it for yourself, or yourselves if there is more than one person still reading this piece. There was no spring in the step and, when it came to other tools available for smoking cessation, the propositions were not about support but about punishment. The three wrote of an “arsenal of evidence-based tools, such as further increases in taxation and decreased availability, that can further reduce smoking prevalence with far less risk of known—and unknown—adverse health effects.”

    Why is it that such people believe smokers should be subjected to restrictions not imposed on others, many of whom also indulge in risky behaviors? I could probably understand their position if the extra taxes they call for were ringfenced for use in supportive quit schemes, but they are not. They go into general revenue where they are used to pay for things that benefit the wider public. Perhaps nonsmokers need to think about declaring an interest when they call for additional taxes on smokers.

    *Nicholas S. Hopkinson, professor of respiratory medicine and chair of Action on Smoking and Health (U.K.); Jorgen Vestbo, professor of respiratory medicine; Andrew Bush, professor of pediatrics and pediatric respirology and the European Respiratory Society’s guidelines director; and Jonathan Grigg, professor of pediatric respiratory and environmental medicine and chair of the European Respiratory Society’s tobacco control committee.