Tag: George Gay

  • 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.

  • Unnecessary Force

    Unnecessary Force

    Using medical licensing to get smokers to switch to vaping products is like using a hammer to crack a nut.

    By George Gay

    On the face of it, the U.K.’s big tobacco/nicotine news story of 2021 was the announcement that e-cigarettes and other inhaled nicotine-containing products could in the future be prescribed through the National Health Service (NHS) in England. Of course, the problem with “could” stories is that they come pre-loaded with “might not” stories. And there is the nagging concern, also, that this story is not quite as new as it seems. But let’s start on a positive note.

    An Oct. 29 press note issued by the peculiarly named Department of Health and Social Care and Office for Health Improvement and Disparities said the Medicines and Healthcare products Regulatory Agency (MHRA) had published updated guidance paving the way for medicinally licensed e-cigarettes to be prescribed for tobacco smokers who wished to quit smoking. The health and social care secretary, Sajid Javid, was quoted as saying that opening the door to a [sic] licensed e-cigarette prescribed on the NHS had the potential to tackle the stark disparities in smoking rates across the country, helping people to stop smoking wherever they lived and whatever their background.

    “Manufacturers can approach the MHRA to submit their products to go through the same regulatory approvals process as other medicines available on the health service,” the story said. “This could mean England becomes the first country in the world to prescribe e-cigarettes licensed as a medical product. If a product receives MHRA approval, clinicians could then decide on a case-by-case basis whether it would be appropriate to prescribe an e-cigarette to NHS patients to help them quit smoking.”

    In fact, this statement was qualified by a background note saying e-cigarettes could be prescribed only after the National Institute for Health and Care Excellence (NICE) had recommended them for use. It did not spell out the circumstances under which NICE might recommend or reject such prescribing, but it is likely that one possible case for rejection would be a poor cost/benefit ratio.

    Nevertheless, the announcement was generally well received. Philip Morris International said in a note published on its website that it supported the U.K. government’s plan to simplify the pathway to license electronic cigarettes and other inhaled nicotine-containing products as medicines in England.

    At the same time, John Dunne, director-general of the U.K. Vaping Industry Association, said in a press note the government deserved “huge praise for taking this bold decision to look more closely at the use of vaping when it comes to smoking cessation and for taking an evidence-based, science-led approach rather than the nonsensical anti-vaping, anti-harm reduction stance of some countries.”

    Meanwhile, Doug Mutter, director of VPZ, which recently launched a vape clinic service across its retail network of 157 U.K. stores, said in a press note that he believed vaping products being prescribed through the NHS in England could provide a huge leap forward in the country’s ambitions to be smoke-free by 2030. “We fully welcome the news that the NHS in England is exploring opportunities to prescribe vaping products to help people quit smoking,” he said. But he added that he believed it was not simply about prescribing a vape product and smokers going away and quitting smoking. “People need education, expert knowledge, support, advice and a personalized service that meets their individual needs,” he said. “Our vape clinic service responds to this demand and is filling a huge void left by [cuts to NHS] stop-smoking services…”

    This need for consumer support had echoes in a new nationwide initiative launched at the end of October and aimed at providing guidance to frontline nursing staff at U.K. hospitals. The initiative, which was being rolled out to every NHS trust by the U.K. Vaping Industry Association and the stop-smoking app, Smoke Free, provides access to a range of resources that provide healthcare practitioners with the knowledge needed for them to give sound advice on how to switch from conventional cigarettes to vape products. It follows a decision by the NHS earlier this year to trial the use of vapes in selected hospitals.

    Qualified support

    A number of health professionals working in tobacco control also welcomed the government announcement, but many qualified their support. Probably, the most common concern was that, because the process of obtaining a medicines license, even if simplified, would still be complex and expensive, only tobacco companies would be able to attempt it.

    There were basically two strands to this concern. One was that some healthcare professionals found the involvement of tobacco companies distasteful, tout court, while another was that consumers might be encouraged to try only licensed, tobacco-company products when other, unlicensed but more efficacious products were available.

    This second argument is interesting partly because it raises the question of how much importance would consumers attach to a medicines license. After all, few smokers in the U.K. today started their habit at a time when the risks of smoking were unknown, so we can assume they are not severely risk averse.

    Given this, I think it would be reasonable to assume that not all of those who tell researchers they are looking to quit smoking want to do so for health reasons. Additionally, the question raised about the importance smokers attach to health concerns is underlined in the U.K. because switching from smoking to vaping stalled some time ago even though Public Health England (an executive agency of the Department of Health and Social Care whose health protection and health improvement responsibilities were split between two other bodies at the start of October 2021) was on record as saying vaping is probably 95 percent less risky than smoking.

    And despite PMI’s positive reaction, it cannot be assumed that all tobacco companies would want to go down the medicines license route. I cannot help thinking, for instance, that it would be something of a disadvantage in getting a product tied to a medicines license because, I assume, it would become petrified within an overall market that was dynamic. Unless the process of obtaining and holding a medicines license for vaping products in the U.K. is to be changed substantially, even obtaining permission to change the font size on the packaging would entail an involved process.

    At least, this is what I was told while previously writing a few stories on Voke, which was or is a product developed over 12 years by Kind Consumer and licensed by the MHRA as a medicinal product that was a safer alternative to combustible cigarettes. Voke was not a vaping product but an alternative nicotine-delivery system that used pharmaceutical-standard inhaler technology in a device closely resembling a traditional cigarette in both the way it looked and in the way a consumer, in using the device, mimicked most of the rituals of smoking. Voke, which had no batteries and no electronics and therefore generated no heat and no chemical reactions and produced neither smoke nor vapor, just an invisible, cool, odorless aerosol, could be used anywhere. And its environmental credentials were good given that it was a relatively simple device made of metal, card and plastic: materials that can be recycled.

    And yet, despite its medicines license and all the other apparent advantages it offered, it didn’t take off. It is worth noting, however, that British American Tobacco, which had cooperated with Kind in developing Voke, pulled out of the arrangement before the product was launched. It is worth noting, too, that Voke was launched as a consumer product in normal retail outlets, not in pharmacies, and not much seemed to be made of its having a medicines license. Finally, its much-delayed launch was not helped by coinciding with the arrival of the coronavirus pandemic.

    Beyond the soundbites

    I don’t want to be too downbeat, but it has to be said that the e-cigarettes announcement was made by a government better at sound bites than policy. The reference by Javid to tackling “the stark disparities in smoking rates across the country” would have been meant to have fed into government claims to be intent on levelling up the country, a strategy being honored more in the breach than the observance. Whether the policy announcement will survive mixing with the realities of an NHS struggling from the effects of more than 10 years of austerity and those of the Covid-19 pandemic remains to be seen.

    In this regard, it was interesting that one healthcare professional who welcomed the announcement as “excellent news” went on to say one of the reasons why one in three U.K. smokers had not tried e-cigarettes was because of the perceived cost barrier. Having approved devices prescribed would therefore help those least able to afford e-cigarettes.

    This raises some interesting questions, not least of which is whether the government has thought through the costs involved if e-cigarette prescriptions started to be given out liberally. And even if it has, has it decided whether ex-smokers should be allowed e-cigarettes on prescription for the rest of their lives rather as a diabetic is provided with insulin for life?

    If you follow the logic of most thinking on nicotine addiction, you would have to say that cutting off prescriptions for e-cigarettes at some time in the future would lead only to relapse. Another question is whether the government could hold the line if, after prescribing came in, young, nonsmokers started to cut out the middleman and take up vaping in numbers, as seems possible.

    The question has to be faced, also, as to whether general practitioners would be happy to prescribe e-cigarettes. The first step in encouraging them to do so would be convincing many of them that nicotine in the doses delivered by e-cigarettes was not harmful. But even so, there is the question of whether in asking them to do so you would be causing them to be conflicted.

    Credit: kues1

    The obvious answer to this is that healthcare professionals are generally accepting of the concept of harm reduction, but for some I’m sure there would be a difference between giving to heroin addicts clean needles from a medical supplies company and providing smokers with e-cigarettes from a tobacco company. Such conflicts have surely been reflected in the labored approach the U.S. Food and Drug Administration has taken since being saddled with overseeing a harmful product.

    A simpler solution

    To my way of thinking, one of the best comments on the government announcement came as part of a quote on the Science Media website by Peter Hajek, director of the Tobacco Dependence Research Unit at the Queen Mary University of London, who admitted to being ambivalent about the plan. Hajek welcomed the fact that the initiative provided a positive message that e-cigarettes were much less risky than smoking and helped smokers quit.

    “Overall, it would seem easier to just recommend existing products, which are well regulated by consumer protection regulations,” he said. “There is sufficient evidence available now that these products are effective and dramatically reduce the risks of smoking.”

    I’m not sure what Hajek meant by “recommend,” but all the government needs to do to promote the shift from smoking to vaping is to allow manufacturers of e-cigarettes complying with consumer protection regulations to state on packaging and advertising agreed wording to the effect outlined by Hajek: “these products are effective and dramatically reduce the risks of smoking.”

    It seems to me that, as things stand, using medicines licensing to try to shift smokers from cigarettes to vaping products is like taking a hammer to crack a nut because I’m not convinced the changes made by the MHRA to its guidance for licensing e-cigarettes as medicines would produce the results sought.

    I was told the key changes made relate to guidance on the quality standards for dose uniformity, nonclinical toxicological data requirements and the design of the clinical pharmacokinetic studies. The updates were said also to reflect changes to the regulatory environment post-Brexit.

    John Britton, emeritus professor of epidemiology at the University of Nottingham, in generally welcoming the government announcement, made the point on Science Media that what was needed urgently was a bespoke regulatory system for all nicotine products that allowed market access and endorsement by health professionals in inverse proportion to those products’ health hazards.

    This, to my mind, is correct. The question remains, however, just how bespoke the system needs to be to work. I’m not convinced the changes announced will be enough. In fact, I’m not convinced any bespoke system complying with the necessarily rigorous demands of the MHRA would give rise to a workable system. I hope I’m wrong.

  • Gay: Taxing Decisions

    Gay: Taxing Decisions

    Credit: Orlando Bellini

    Higher taxes and graphic warnings are not the best ways to encourage smokers to switch to ENDS.

    By George Gay

    Towards the end of August, the U.S. Food and Drug Administration announced that it had issued marketing denial orders (MDOs) in respect of about 55,000 flavored electronic nicotine-delivery system (ENDS) products. At about the same time, the FDA announced also that the deadline for combustible-cigarette manufacturers to print new health warnings on their products and product advertising had been delayed until October 11, 2022.

    I think these two developments will strike you as odd if you subscribe to two almost universally-held ideas: that the consumption of combustible cigarettes kills and that graphic health warnings help to discourage people from such consumption; and if you subscribe to the idea that is less widely held: that ENDS are the most effective products for helping people quit smoking.

    Indeed, to say that these two developments seem odd is something of an understatement. They represent a world turned upside down; a world in which the consumption of combustible cigarettes, which are regarded as deadly, is not discouraged, while the consumption of less-risky, cigarette-substitute products is discouraged.

    Credit: Timothy S. Donahue

    It is important to say, however, that what has happened is not entirely down to the FDA, which, in line with its obligations under the Tobacco Control Act of 2009, initially tried to bring in graphic health warnings on combustible cigarettes about 10 years ago, only to have them challenged in the courts and declared unconstitutional. The latest attempt at bringing in such warnings, the details of which became known in 2020, was similarly subjected to challenges, and to court-imposed delays.

    However, it is reasonable, I think, to quarrel with the types of warnings proposed, which seem in large part to follow the same tired pattern of those used in other countries and regions. For instance, the proposed U.S. graphic warning pictures and captions, in line with those introduced elsewhere, do not tell the full story – that is, they don’t tell the whole truth.

    Just to take one example; the caption on one picture reads, Warning: Smoking causes cataracts, which can lead to blindness. I don’t smoke, but I have cataracts forming; so obviously there are other causes of cataracts, the biggest of which I would say is probably, as in my case, getting old.

    If there is to be an honest attempt at informing smokers, the cataracts warning needs to answer a lot of questions specifically aimed at people living in the U.S., questions that could be answered easily on a pack insert. Are there other causes of cataracts and what are they? At what age do smokers and non-smokers generally start to suffer from cataracts? Are cataracts more common in smokers than in non-smokers? Given that removing cataracts is one of the more common and more successful operations performed, how often do cataracts lead to blindness? Is the incidence of cataract-induced blindness more common among smokers than in the general population?

    That the caption doesn’t answer these questions and the others that might rightly be raised by smokers, in my view is down to the paternalistic attitude of the FDA – and agencies in other countries that are in charge of determining the form of such warnings. Largely, I think, because smokers tend to be found in what are termed lower socio-economic groups, it is assumed they have to be told what is good for them without bothering their heads with details; whereas, in fact, some of them are rather smart.

    Meanwhile, the FDA, while not being directly responsible for the delay in requiring health warnings on cigarette packs and advertising, is, in my view, more culpable in respect of the muddle over ENDS products. Basically, it has become hoist on its own petard – entrapped by its own propaganda about youth vaping.

    In issuing its MDOs in August, the FDA said it had determined that the “applications for about 55,000 flavored ENDS products from three applicants lacked sufficient evidence that they have a benefit to adult smokers sufficient to overcome the public health threat posed by the well-documented, alarming levels of youth use of such products. The products from JD Nova Group LLC, Great American Vapes, and Vapor Salon subject to this action are non-tobacco-flavored ENDS and they include flavors such as Apple Crumble, Dr. Cola and Cinnamon Toast Cereal.”

    This whole idea of considering public health, or population-wide health, rather than individual health, has its merits, but it is also flawed; as is the idea of utilitarianism on which it seems to be loosely based. If the idea is to bring about the maximum good for the maximum number of people, the calculations necessary become overwhelming and, in part, require the foretelling of the future.

    As the FDA says, the applicant must demonstrate that the product is appropriate for the protection of public health. “This public or population health standard is quite high and requires considering the product’s risks and benefits to the population as a whole, including users and nonusers of the tobacco product, and taking into account the increased or decreased likelihood that existing users of tobacco products will stop using such products, and the increased or decreased likelihood that those who do not use tobacco products will start using such products,” it says.

    If a doctor you have consulted wants to prescribe for you an inhaler, is it incumbent upon her to take into account the fact that the production of that inhaler, and all the inhalers you will need for the rest of your life, will produce CO2 emissions that will exacerbate the existential climate crisis we have created and, therefore, the health of Joe Blow, who will then need an inhaler so that there are now two such devices being produced on a regular basis along with more CO2…?

    To my way of thinking, it makes sense to consider population-wide health effects where there is a population-wide health threat, such as that caused by pollution, which is a far bigger killer than is tobacco smoking but which is largely consigned by those who should be tackling it to the too-hard drawer. But it seems to make little sense where what is in question comprises health threats to individuals and possible solutions for those threats.

    Of course, what those who like to consider population-wide health benefits or threats will tell you is that there is no point in allowing the sale of vaping devices so that middle-aged Joe Blow can use such devices to quit smoking if young man John Doe takes up vaping and goes on to become a smoker, at least when this example is extrapolated across the population. I really don’t accept this argument because, to me, Joe and John are individuals, as are all the other people who make up the population and who make their own choices about what they do with their lives.

    What has happened here is that, as mentioned above, the FDA has found itself hemmed in by its own propaganda. Take another look at that part of the FDA’s statement above where it tries to justify dumping 55,000 vaping products and where it talks of: ‘the public health threat posed by the well-documented, alarming levels of youth use of such products’.

    To me, the use of the word “alarming” is an example of where the FDA’s claim to scientific rigor runs out of road. Compare what the FDA had to say with what was stated recently in a report entitled, Balancing Consideration of the Risks and Benefits of E-Cigarettes, which, I understand, was penned by 15 past presidents of the Society for Research on Nicotine and Tobacco.

    Although the authors argue that the overwhelming focus of US policies and media attention on decreasing youth vaping has distracted from the goal of reducing smoking, they concede that: “Still, concerns emanating from substantial increases in youth vaping in 2018 and 2019 are readily understandable and important to address.”

    It is also important to take note of something else that I think is significant. A contributor to the Global Forum on Nicotine held in the UK earlier this year explained how U.S. government policies were driven by the fears and wishes of the majority population, made up of the suburban, white, middle-classes. This was why tobacco smoking, a habit mainly of the financially less-well-off, had been largely tolerated [health warnings delayed again], while vaping, the subject of scare stories about an epidemic among the children of the middle class, had launched a moral panic [55,000 products dumped].

    The Balancing Consideration report is indeed a model of balance; as can be glimpsed from this passage: ‘Smokers unable to quit smoking with evidence-based cessation methods should be well informed about the relative risks of vaping and smoking and vaping’s potential to help them quit smoking. They should understand that, while the long-term health consequences are unknown, completely substituting vaping for smoking likely reduces health risks, possibly substantially.

    Dual use of cigarettes and e-cigarettes will not have a comparable beneficial effect. However, a period of dual use may be necessary for some smokers to transition from smoking. Because vaping itself poses some risk, the best advice is to eventually stop vaping as well.’

    I find it impossible to argue with almost anything in this passage or in the objective of the authors, which is to encourage more balanced consideration of vaping within public health and in the media and policy circles. There is certainly a need for such balance. As the authors say in the introduction to the report: “Opponents focus on e-cigarettes’ risks for young people, while supporters emphasize the potential for e-cigarettes to assist smokers in quitting smoking.

    Most U.S. health organizations, media coverage, and policymakers have focused primarily on risks to youths. Because of their messaging, much of the public – including most smokers – now consider e-cigarette use as dangerous as or more dangerous than smoking.”

    The authors are correct; this is a situation that needs to be rectified.

    And yet, I cannot go along with everything in the report, though it talks with empathy about smokers. “Today’s smokers come disproportionately from lower education and income groups, the LGBTQ (lesbian, gay, bisexual, transgender, and queer or questioning) community, and populations suffering from mental health conditions and from other drug addictions,’ it says. ‘Smoking accounts for a significant proportion of the large life expectancy difference between affluent and poorer Americans.”

    And the report is right in making the point that a lot of people hardly realise that smokers still exist. “To the more privileged members of society, today’s smokers may be nearly invisible,” it says. “Indeed, many affluent, educated US persons may believe the problem of smoking has been largely ‘solved.” They do not smoke. Their friends and colleagues do not smoke. There is no smoking in their workplaces, nor in the restaurants and bars they frequent. Yet one of every seven U.S. adults remains a smoker today.”

    But then, to my mind, the report loses its way. “Tax cigarettes and other combustible tobacco products heavily; impose a more modest tax on e-cigarettes,” it advises. “Taxes should be proportionate to risk. A much higher tax on combustibles will encourage adult smokers to quit smoking or to switch to less expensive e-cigarettes. By raising the price of e-cigarettes, a modest tax will discourage their use by price-sensitive youths.”

    There are several problems with this, I would suggest, partly perhaps because, I suspect, the authors don’t smoke and don’t generally rub shoulders with those in the lower socio-economic groups. The authors want to tax smokers heavily having already declared that these people generally come from groups less well-off financially. They say that this is to encourage smokers to stop smoking, but it is nothing of the sort. It is an attempt at bludgeoning them into giving up.

    To my way of thinking, if a smoker is given the facts about her habit, partly through the medium of comprehensive, fact-based health warnings, and she chooses to keep smoking, that is her business. Hitting her with levels of taxes that would not be tolerated but for the fact that smokers comprise an unrepresented minority is grossly unfair.

    And what will happen to the money raised? Will it be spent on helping these people? The record shows that this will not be the case. The money will be spent on politicians’ vanity projects, while nine million children will still go hungry.

    And finally, what about the seemingly worthwhile aim of increasing the life expectancy of these smokers by bludgeoning them into quitting? Given that the last years of these people’s lives are hardly likely to be halcyon; it might be a good idea to ask them if they really want another 10 years of struggling to make ends meet as they become increasingly infirm. Walk – or perhaps hobble – a mile in my shoes.

  • The Watchful Eye

    The Watchful Eye

    Credit: Sergey Nivens

    Tobacco companies should be allowed to transition to harm reduction products, but under history’s watchful eye.

    By George Gay

    I don’t go along with the oft-repeated idea that, if we don’t remember the past, we are condemned to repeat it. This is not to say that particular versions of the past, whether real or invented, are not repeated, just that mostly it is impossible to know whether an event is an original or a repeat. For one thing, memories of the past are mostly not the result of direct experiences and so are not fixed and generally agreed. History, into which the past is roughly sieved, is never objective. It is most often weighted, open to interpretation and subject to disagreements.

    I would be happy to consign all versions of history to oblivion, but then, as somebody famously said, there would be no point. In saying that we consign something to oblivion, we suggest that it is simultaneously forgotten and preserved. We are incapable, it seems, of letting go of favorite versions of the past, which get stuck to our shoes like carelessly discarded chewing gum.

    Specifically, it concerns me that history, or versions of it, are being allowed to act as a drag on advances that could be being made in reducing the health consequences of cigarette smoking. I recently attended a nicotine conference and, as part of one generally good presentation, a still of a video was shown in which CEOs from U.S. tobacco companies told a Congressional oversight committee sitting a quarter of a century ago that they did not believe nicotine was addictive. I have seen this still, or similar ones, on more occasions than I care to remember, often presented as shorthand for how heinous the tobacco industry was or even is.

    But one problem in my view is that what is presented here is a version of history directed by the enemies of the tobacco industry who feel they won the moral war. In other words, a history presented by the victors. It implies that those CEOs were willing to lie about something that everyone knew to be true—that nicotine was and is addictive. There is no time for nuance in a single still. There is no room for other interpretations.

    Credit: Sky Next

    For instance, were all the CEOs referencing the same, agreed version of addiction? And if, as generally supposed, they were all referencing the same definition of addiction, were they acting in bad faith, or were they, or at least some of them, not informed or badly informed by the scientists working in their companies who did believe that nicotine was addictive? Is it possible the CEOs were right and everybody else was wrong? Was one or more of them delusional and in need of help?

    I ask above whether all of the CEOs were referencing the same definition of addiction and, frankly, I have no idea what the answer to that question is. I tend to the view, however, that they were, because I find it difficult to believe their legal teams would have allowed them to give the answers they did without knowing exactly what they were signing up for.

    But I have one troublesome doubt in this regard. As far as I am aware, five of the seven CEOs who testified in 1994 said they believed that nicotine was not addictive; one said he believed that neither nicotine nor his company’s products were addictive while another said he believed cigarettes and nicotine clearly did not meet the classic definition of addiction because there was no intoxication.

    The reference to “the classical definition” surely suggests that it was admitted there was more than one definition, which possibly means the answers need to be interpreted individually. Additionally, it cannot be ruled out that even if a CEO knew that his company’s scientists believed nicotine to be addictive, his personal view might have been different. We all become fed up with experts at one time or another.

    The oversight committee’s hearings later revealed that all sorts of skulduggery had gone on; for instance, at least some of the people within these companies knew or believed that nicotine was addictive and that some had manipulated their products to try to make them more addictive, whatever that means in the context of whatever definition you are using.

    But where did this information come from? It came in part from documents voluntarily handed over to the committee at the behest of the CEOs. This seems to suggest that the CEOs were either not aware of what was in those documents or that they were not aware of all that was in them.

    But let’s say for the sake of argument that the CEOs, or at least some of them, told the committee they believed nicotine was not addictive, knowing that all this skulduggery had been going on—would they not have been acting in exactly the way they would have been expected to act—perfectly in line with business and societal norms? After all, they were CEOs charged with maximizing company profits at a time when greed was good, so there was some collateral damage. But then, starting only with the “A’s,” look at the alcohol, arms and automobile industries.

    I don’t want to defend what the CEOs said during that committee hearing or what the tobacco industry got up to because I don’t know enough about this stuff. But it seems a little odd to me that, at a time when the U.S. was deep in the grip of neoliberal dogma, these men (they were all men) were condemned for following the logic of the market and maximizing profits.

    But the committee seemed to want to set itself above all of this tacky business stuff, somewhere on the moral high ground. This is, in part, what the chairman on April 14, 1994, said in opening the hearing: “For decades, the tobacco companies have been exempt from the standards of responsibility and accountability that apply to all other American corporations. … This hearing marks the beginning of a new relationship between Congress and the tobacco companies. The old rules are out; the standards that apply to every other company are in.”

    I would imagine that what a lot of people took away from this, whether it was meant or not, is that there goes the wicked tobacco industry again, avoiding its responsibilities for decades. But, if the finger is to be pointed anywhere, it should surely be pointed at Congress, which, as is more or less admitted by the chairman, allowed this situation to exist and to continue. It cannot be expected that businesses will, in the normal course of things, lobby Congress to saddle themselves with additional regulations.

    I thought the opening remarks strange in another way also. The chairman at one point says: “Nearly a half million Americans die every year as a result of tobacco. This is an astounding, almost incomprehensible statistic. Imagine our nation’s outrage if two fully loaded jumbo jets crashed each day, killing all aboard. Yet that is the same number of Americans that cigarettes kill every 24 hours.”

    As I see it, the chairman is making a comparison as part of what I suppose was meant to be a moral argument, but that comparison does not stand up to even basic scrutiny. As human beings, we take risks every day, balancing those risks, either consciously or unconsciously, against perceived benefits. Smoking and drinking alcohol are two obvious everyday examples of this. And so, too, for a lot of people (though perhaps not recently) is getting on an airplane. As things stand, people get on airplanes because they are overwhelmingly safe to use, so the benefit-to-risk ratio is hugely positive.

    But it is inconceivable that if two jumbo jets crashed each day in the U.S. alone, people would still board them. The chairman was ignoring the fact that people make risk assessments so as to conjure up a situation that would never occur. People understand that smoking might cause them to die in 40 years to 50 years, and they understand that falling from 30,000 feet brings on death a lot quicker.

    The idea of risk can be manipulated, and often is, as in the story about the therapist with a patient who is still nervous of flying even after being told that the chances of a bomb being on board a plane is a billion to one; the therapist advises her to take her own bomb on board next time she flies because the chances of there being two bombs on board are a trillion to one.

    I need to emphasize that I am not trying to defend the past behavior of the tobacco industry or the CEOs in question. What concerns me here is that a single picture is being regularly presented as telling a story that is far simpler than it really is. What has passed into history—what I would imagine most people would “remember” from the picture of the subcommittee hearing—was that all of the CEOs lied in saying that nicotine was not addictive. I doubt that many people would realize that what they said was they believed nicotine was not addictive, let alone the back story to this event.

    This is the problem with the versions of history we drag around with us. In the end, what did the hearings bring about? Reputational damage to tobacco companies for sure. But they are still operating in one form or another, and part of their business is largely unchanged. It is said that the number of smokers fell after the hearings, but who knows whether the hearings were a causal factor in this.

    It is more interesting to examine what continued: taxes. Local, state and federal agencies continued to benefit from people smoking through the taxes they paid, and later was added the proceeds of the Master Settlement Agreement, very little of which is ever spent on ameliorating the toll of tobacco smoking; so who gets to stand on the moral high ground?

    Credit: Gawriloff

    Well, the answer to that question might seem strange. I say above that it is not usual for businesses to lobby Congress to try to saddle themselves with additional regulations. But, in fact, odd as it might seem, this is exactly what many nicotine and tobacco companies have been doing in recent times.

    I’m not saying they are perfect and that part of this new way of thinking hasn’t to do with competition, but in part it is a genuine attempt to ensure that the new generation products that are being developed and offered to help people transition to safer forms of nicotine consumption are not causing, and can be seen not to be causing, unintended consequences.

    And for those people who tend still to be wedded to the idea portrayed by the still of the tobacco CEOs, it is worth noting that, importantly, in the recent past the major tobacco companies have found a way of offering reduced-risk products while roughly maintaining the sorts of business models that were so successful for them in the past. Does this put them on the moral high ground? Of course not, but it has mapped out a route to that ground.

    Times are changing, and we desperately need to stop slowing the transition into a new world of nicotine consumption by constantly dragging behind us a little-examined history of what went on 20 years to 30 years ago—a time that few working in the nicotine and tobacco industries could probably remember.

    There was a furor just after I started to write this piece about a proposed takeover by Philip Morris International of the pharmaceutical company Vectura, which in news reports was said to be developing inhaled treatments for respiratory diseases. Why the furor? Well, it’s all about history, of course. PMI has in the past sold traditional cigarettes and still does; so, the detractors claimed, we cannot let it near a pharmaceutical company.

    There seems to be no way such people can accept that, in order to move ahead with the transition from smoking to other forms of nicotine consumption, we have to look at innovative, even daring ways of doing things.

    I have no insights into what PMI is up to beyond what has been reported in the general press, but it doesn’t take a genius to figure out that it might be looking, in part, to benefit from some cross fertilization of ideas in respect of inhalation technologies—ideas that just might allow it to make a breakthrough in respect of reduced-risk, next-generation nicotine products.

    At least we should allow companies to try such things—while keeping an eye on them, of course. We should not let history stand in the way.

  • Gay: Politicians Think Nicotine Users Are Broken

    Gay: Politicians Think Nicotine Users Are Broken

    By George Gay

    If you are struggling to work out whether you and your fellow human beings will be able to save the only planet on which we can live from being made uninhabitable by climate change, it is possibly because you are looking in the wrong direction for the answer—you are looking at the data, which, because it comprises complex inputs from many interacting sciences, is impossible for a layperson to interpret.

    But never mind; I have cut through all this data for you and come to a conclusion that I believe is rock solid. No, we won’t save the world.

    And to become a fellow believer, you need look no further for evidence than the existence of the powered leaf blower. That people, with the possible exception of the disabled, buy these things rather than brooms during a climate emergency engendered largely by the overuse of unrenewable energy provides indisputable evidence that humans refuse to engage their brains and, therefore, won’t—and probably shouldn’t—survive.

    There is a man of my acquaintance who uses a powered blower to corral the leaves in his garden, which is the size only of one of those large, starched napkins beloved, for good reason, of spaghetti eaters, and at the front of his house, including the pavement, which forms a larger area.

    It is fascinating to watch him because, like a dog rounding up sheep, he has to keep going back for stragglers, which are often stragglers only because they have been hit by a puff of wind, possibly caused, in part, by climate change, which, in turn, is being exacerbated by the use of the leaf blower …

    But his offense is worse than this because, after corralling his leaves, he gets into his car, which is not much smaller than a bus capable of carrying half a dozen people and all their worldly goods, and drives off, alone, to the gym, contributing as he goes to the already high and probably illegal levels of pollution we happily maintain in these parts.

    Credit: Good Ideas

    He could have obtained a good level of exercise by wielding a broom at those leaves, but no, he prefers to burn fossil fuels driving down to the gym where he mounts an exercise machine manufactured using huge amounts of energy and materials dug out of the ground or manufactured so as to be, like Tithonus, cursed with an immortality not mitigated by eternal youth.

    At least you would think that the machine he mounts would be connected to the gym’s power supply so that the work he does has some purpose. But no, this is a lesson in entropy, so the work he does is converted into heat that causes the gym’s air-conditioning system to kick in, burning more energy …

    And as my acquaintance works on his machine, happily watching his pain and discomfort reflected back at him by giant mirrors, keenly monitoring on his wrist-mounted electronic device the state of organs whose position in his body he couldn’t identify, and listening distractedly to music delivered through sweat-encrusted headphones, his wife is vacuuming the house—getting rid of the dust that, in no small part, comprises small leaf particles created and driven into the air by the actions of her husband and his leaf blower.

    Is this sensible? Of course, I admit that, even though there are a lot of people like my acquaintance and his wife, to a certain extent, what individuals can do to help ameliorate the climate emergency is a drop in the ocean compared with what could be done by businesses, industries and governments, but I think the situation would be helped if individuals showed a greater awareness of the problems we face and the sorts of actions that are plain stupid if the aim is to save the planet.

    In that way, perhaps, they would be in a better position and more likely to put pressure on businesses, industries and governments to take action. After all, it would be awful to go out with a whimper.

    There is no point in expecting politicians to act logically without their being pressured to do so because, as somebody nearly once said, people are governed by parliaments, not by logic. Unfortunately, we in the tobacco and nicotine industries are similarly governed—not by logic, but by governments largely swayed by half-baked ideas delivered by lobbyists, broken economic systems and pollsters, not to mention great dollops of hypocrisy.

    So my eye was caught recently by the heading of a May 7 story by Sarantis Michalopoulos for EURACTIV.com based on an interview with Michele Rivasi, who was described as a French EU lawmaker from the group of the Greens/European Free Alliance (Europe Ecologie) of the European Parliament, MEP: E-cigarettes have a place in the EU Cancer Plan, but we must remain vigilant. Given this was a report based on an interview with a Green politician, I was keen to read it because I am interested in the environmental credentials of e-cigarettes, a subject that doesn’t seem to attract enough debate.

    However, I was disappointed. This was another of those fence-sitting exercises in which the risk-reduction characteristics of e-cigarettes are acknowledged but in which it is said that nothing should be done to encourage their use, which seems to miss the point that if their use isn’t encouraged, then their risk-reduction potential remains hanging in limbo.

    Credit: Balint Radu

    “E-cigarettes ‘undoubtedly’ reduce risks compared to traditional cigarettes and have a place in the EU’s plan to fight cancer,” Michalopoulos quotes Rivasi as saying. “However, these products should not enjoy ‘lighter’ regulation, and Europe should treat them with the same vigilance as tobacco products. I see no reason why the electronic cigarette and its products should benefit from tax reductions or exemptions.”

    What is being said here? Well, as I read it, nothing helpful or rational. Rivasi seems to be saying that traditional cigarettes and e-cigarettes are, at one and the same time, different but the same. These products are so different that e-cigarettes can be seen as part of the weaponry with which to fight cancer, whereas traditional cigarettes comprise part of cancer’s own armory. But, at the same time, they are so similar that they should be treated the same when it comes to regulations and taxes.

    You have to wonder what Rivasi believes smokers will make of such a stance, if indeed it can be regarded as a stance. Most smokers, I imagine, make some kind of compromise in moving from traditional cigarettes to e-cigarettes, perhaps in respect of satisfaction, taste, convenience … Even so, in the early days of e-cigarettes, it was probably relatively easy to get smokers to convert because many of them were willing to make compromises simply on the basis that they were moving to a less risky product.

    Now, in those countries where a significant level of conversion has taken place, it becomes necessary to try to reduce the compromises that must be made and, in this way, encourage more-committed smokers to convert. Tobacco and nicotine businesses tend to do this simply because they are in competition; they want their products to be more satisfying, tasty and convenient than those of their competitors.

    But an important way of reducing the compromises that have to be made is through price—i.e., tax—differentials or through regulation, such as that allowing the use of e-cigarettes in at least some public places where traditional cigarettes may not be smoked. Lumping together traditional cigarettes and e-cigarettes in respect of taxation and regulation is simply ridiculous if the aim is to get smokers to transition to vaping. It sends out a signal that e-cigarettes do not offer a real health benefit.

    Rivasi has more to say on products that to her way of thinking are similar. “For us, the Greens, if the use of electronic cigarettes is claimed to be an alternative to tobacco [use], as a substitute product or as a way of reducing the ravages associated with conventional cigarettes … we need to consider electronic cigarettes as a medical device in the same way as gum or patches are pharmaceutical products,” Michalopoulos reports Rivasi as saying.

    I’m not sure whether a distinction is being made here between a medical device and a pharmaceutical product, but I assume not. So what seems to be being said is that if e-cigarettes are claimed to be a substitute for or alternative to traditional cigarettes, they should be treated as if they are nicotine-replacement products (NRTs), an idea that seems to ignore the fact that NRTs are not consumer products and therefore cannot be seen as substitutes for or alternatives to traditional cigarettes.

    Again, the lack of logic drives you to impossible places. If, as above, it is claimed that NRTs are the same as e-cigarettes, which are the same as tobacco products, you have to assume that all three should be taxed at the same level and subject to the same regulations. So, for instance, people shouldn’t be allowed to wear nicotine patches in enclosed public places.

    Quite clearly, this would be ludicrous for a number of reasons, and the problem stems from trying to pretend that different things are the same. Traditional cigarettes and e-cigarettes are two similar but different consumer products, whereas NRTs are medical devices, even though, in the U.K., for instance, they have been licensed for harm reduction rather than just cessation.

    During the interview, we get much else that seems to discourage the use of e-cigarettes. We get the EVALI (e-cigarette or vaping use-associated lung injury) distraction and a totally unconvincing passage about what Rivasi sees as the gateway vaping provides to smoking.

    Credit: Aleksej

    Later, she is quoted as saying the shortcomings of legislation concerning heated tobacco and electronic cigarettes are known. “We need better regulation of sales and advertising, a thorough analysis of additives and their cocktail effect, a ban on flavorings and mandatory health warnings to alert nonsmokers to the risks, as is the case for traditional cigarettes,” she is reported as saying.

    These are just throwaway lines. What does it mean to talk of “better regulation”? Better regulation to somebody steeped in tobacco harm reduction is going to look a lot different to better regulation as seen by those supporting a quit-or-die agenda while goodness knows what better regulation looks like to somebody perched on the fence.

    And what is the point, apart from providing cover for science departments to carry out pointless “research,” in calling for a thorough analysis of additives while at the same time calling for a ban on flavors, which make up a huge proportion of those additives?

    Towards the end of the reported interview, Rivasi moves to a favorite of politicians: the attribution to a group of a claim that the group has not made and then the condemnation of that claim. “The electronic cigarette is undoubtedly a product that can reduce risks, but it is not the panacea its followers—and the companies behind them—would have us believe,” she is quoted as saying.

    I have never heard people who promote e-cigarette use over traditional cigarette use claiming such a move is a panacea. The panacea quip is another throwaway line and one that needs to be thrown away. Indeed, Rivasi knows as much. Earlier in the interview, she is quoted as saying, “The industry itself acknowledges its ignorance and wants to know more about the real impact of its products.” That doesn’t sound to me to be an industry claiming to have already developed a panacea.

    There is something odd here. As I mentioned above, there is no mention in the interview of the area of the e-cigarette debate to which Rivasi could, I assume, make a valuable contribution. How do you compare the environmental impacts of traditional cigarettes, e-cigarettes, other new generation products and NRTs?

    The major problem is that politicians often believe they need to fuss around tidying up the lives of smokers and nicotine users without considering the wider picture. They are like my acquaintance and his use of the leaf blower. In fact, I would much sooner hear Rivasi talking about leaf blowers and patio heaters … There is no point in extending by a few years the lives of some smokers if we’re all going to die prematurely of pollution and the effects of climate change.

  • Taxing the Solution

    Taxing the Solution

    Credit: Farizun Amrod

    Vaping products don’t create costs; they make some of the costs of tobacco use disappear.

    By George Gay

    According to a Vapor Voice news story quoting a CStoreDecisions piece by Isabelle Gustafson, lawmakers have introduced into the U.S. Senate a bill that would establish a federal tax on vaping products and increase the traditional tobacco tax rate for the first time in a decade.

    I quote below three of the five-paragraph news story in full because I believe that some of the points made by those supporting the bill need to be challenged, though I acknowledge that such challenge will not affect the final outcome:

    The Tobacco Tax Equity Act of 2021 aims to “close tax code loopholes for tobacco products by increasing the federal tax rate on cigarettes, pegging it to inflation to ensure it remains an effective public health tool and setting the federal tax rate for all other tobacco products at this same level.”

    “Tobacco-related disease accounts for one out of every five deaths in America, and I know that story firsthand,” Senate Majority Whip Dick Durbin was quoted as saying. “Data shows that the most effective strategy to prevent children from starting this deadly habit is to price it out of their range. This bill would help reduce tobacco and e-cigarette use by ending loopholes that the industry has exploited to target our children. If America can kick its nicotine addiction, it would go a long way to improving our public health for generations to come.”

    “Loopholes in our tax code continue to favor big tobacco while the American public, especially our youth, pays the price,” said Representative Raja Krishnamoorthi. “The Tobacco Tax Equity Act increases taxes on cigarettes and finally imposes taxes on the e-cigarettes hooking our children on nicotine, which would generate billions of dollars in federal revenue. As a father of a high schooler and middle schooler, I’m determined to make sure we end the youth nicotine and vaping epidemic.”

    I would like firstly to question the term “loopholes,” which is used three times, once in the introduction and once each by the two politicians quoted. The word loophole is used normally to convey the idea that some scam is in operation that allows a disreputable individual, corporation or organization to gain an advantage over others by obeying the letter of a law or rule but not the spirit of that law or rule. And that implied criticism is aimed at one of the usual suspects—big tobacco.

    But is this what has been going on here? Has big tobacco been using loopholes in the tax system to target young people? Not from the evidence presented. The politicians quoted seem to be complaining that big tobacco hasn’t been falling in line with tax rules not yet in place, which seems a tad unfair. In other words, the complaints, if any, should be aimed at the politicians for not having brought in these new rules earlier, given that they seem to believe they are so important.

    But it is not the way of politicians to blame themselves or even to admit that they have been neglectful of their duties, so the politicians try to clamber onto the word loopholes as if it somehow represents the moral high ground.

    And on that somewhat unstable ground, they teeter. Durbin is quoted as implying that one or more people from within his circle of family and/or friends died from a tobacco-related disease. I’m sure that most people would sympathize with Durbin at this point, but the problem here is that he is trying to convince people of the correctness of his position by arguing from the particular to the general.

    And the concern must be that despite the fragility of such arguments, other politicians will be won over. It makes you wonder what would happen if a politician called for extra taxes on automobiles because somebody from within her circle had been killed in an automobile wreck.

    What I don’t like, also, about Durbin’s position is that it smacks of collective punishment. Tobacco consumption led to the death of somebody from within his circle, so all tobacco users should be punished through the taxation system, even though what they are doing is legal and even though they had no interaction or involvement with the dead person. Such actions are banned even in war.

    Then, from the dizzying moral heights of language loopholes and particularities, the announcement moves on to the favorite ploy of all: emotional blackmail. We are told that the new taxes will protect “our children”—or, rather, children (three mentions), youth (two mentions) and schoolers (two mentions).

    I wonder how? Perhaps, in the light of not enough attention being paid by politicians to some of the other needs of children, the additional money raised through the new taxes could be used to feed the 18 million children who are projected to face hunger in the U.S. this year. But don’t hold your breath.

    Credit: Auremar

    Krishnamoorthi is quoted as saying that the Tobacco Tax Equity Act “increases taxes on cigarettes and finally imposes taxes on the e-cigarettes hooking our children on nicotine.” Note the use of “finally” here, which I guess is meant to imply that it has taken a long time to bring the bill forward because of the heroic efforts that politicians have had to put in to overcome the huge barriers standing in the way of tax reform, when, presumably, the reason is that they have not been bothered up to this point.

    I would also like to take issue with the idea that Krishnamoorthi trots out about “e-cigarettes hooking our children on nicotine.” Does he know this to be the case, I wonder? Has he proof? It is true that if you look on the website of the National Institute of Drug Abuse, you will see a piece that says, “Consuming nicotine—through regular cigarettes or vaping—leads to the release of the chemical dopamine in the human brain. As with many drugs, dopamine prompts or ‘teaches’ the brain to repeat the same behavior (such as using tobacco) over and over.”

    But according to a review by Rivka Galchen (London Review of Books, April 22) of The idea of the Brain, the author, Matthew Cobb, casts doubt on such an idea. “The connection of dopamine to addictive behavior—Cobb cites a Facebook founder saying the site was meant to be addictive, to ‘give you a little dopamine hit’—is ‘nonsense’ and ‘neurobollocks,’” Galchen quotes Cobb as saying. I am not saying that Cobb is correct. I am not in a position to be able to judge such things, but what he has to say must surely give people, even politicians, pause for thought, for he is not alone in thinking this way.

    One problem in assessing the rights and wrongs of taxing vaping products in the U.S. arises from the fact that politicians have fallen for the Food and Drug Administration’s descent from science to alchemy in “deeming” these products to be tobacco products. Imagine a U.S. in which bread has not been invented and a significant proportion of the population lives on cake as a staple, with the consequence that these people are wobbly fat.

    In trying to improve the situation, the authorities have turned to imposing high taxes on cake, but the sugar content proves to be too appealing, and the people keep buying cake, whether tax-paid or illicit. The authorities then declare war on the cake manufacturers who, after a while, admit that too many wobblies are dying, and come up with bread, with which they claim they can wean at least some of the people off cake.

    What do the authorities do? Do they welcome this development? Not if we are talking about the FDA. They say that bread, like cake, contains flour, and, since there are still small amounts of sugar in bread to make it palatable, bread must be deemed to be cake. At which point, the politicians, desperate for funds, realize that bread can be taxed. Alice has gone headfirst through the looking glass.

    Credit: Highway Starz

    A couple of other points come out of the announcement of the bill. It is clear that part of the aim of the bill is to force the U.S. “to kick its nicotine habit.” But nicotine and tobacco use are both legal in the U.S., so people have the right to consume tobacco and nicotine products. There is a danger here that politicians are going to muddle up issues of ethics with those of rights.

    Just because you object to something on ethical grounds doesn’t bestow on you the right to make it unobtainable for those who don’t go along with your ethical views. In the U.K., we seem to get stuck in the same morass when discussing the issue of assisted dying, and all too few politicians are willing to make the stand that though they might be ethically opposed to assisted dying, they recognize the rights of others to avail themselves of it. As I believe Michel de Montaigne pointed out in the 16th century, “Life is slavery if freedom to die is wanting.”

    At the same time, it seems to me that we enter the tobacco and nicotine tax debate too far along the line. We enter it on the assumption that tobacco and nicotine products should be taxed. But why is this so? Well, one idea has it that products should be taxed according to the harm that they cause. This point was made by a couple of speakers who addressed the Western Economic Association International (WEAI) virtual conference during March.

    According to a news report, one of them, Woo-Hyung Hong, professor in the Hansung University Department of Economics (South Korea), said that tobacco taxes should be based on a product’s external economic costs. Such a system should consider medical costs, loss-of-labor capital costs, costs from cigarette-related fires and avoidance costs, among others.

    There is a certain logic associated with this idea, but if you accept that logic, then surely you have to apply it to everything. Automobiles, for instance. Look at the medical costs that arise from people driving automobiles. There are, of course, the deaths and injuries caused by car wrecks, the deaths and injuries caused by the pollution most automobiles contribute to, pollution that has now been acknowledged to be a bigger killer worldwide than tobacco consumption. And then there is the issue of people becoming wobbly fat because they use their cars rather than walk.

    This, in part, is what the U.S. Centers for Disease Control and Prevention has to say on this subject: “Obesity is serious because it is associated with poorer mental health outcomes and reduced quality of life. Obesity is also associated with the leading causes of death in the United States and worldwide, including diabetes, heart disease, stroke and some types of cancer.”

    And what about the loss-of-labor costs? Well, for a start, all of the medical problems outlined above are likely to lead to such loss of labor, and just imagine the loss caused by people snarled up in highly polluting traffic jams.

    And while most automobiles still run on fossil fuels, there is the billion-dollar cost of subsidizing the oil companies for pumping these fuels out of the ground—fuels, the use of which is causing eye-watering costs associated with climate change and environmental breakdown, costs from which we might never recover.

    None of this is to say that tobacco should not be taxed. We are too far down the road to go back now. But all of the revenue from such taxes should be used to relieve some of the causes that encourage people to take up smoking; one of which is clearly poverty since poverty is a good predictor of the likelihood of a person being a smoker. I believe in the idea of redistributive taxes, but the way that tobacco taxation works at the moment is that it is redistributive “upward,” which is obscene.

    And finally, there is no reason to tax vaping devices. They don’t create costs; they make some of the costs of tobacco use disappear. They are a solution, not a problem.

  • The Voice of Reason

    The Voice of Reason

    The UKVIA does a commendable job of promoting sensible vapor regulations. Will health authorities listen?

    By George Gay

    In March, I received a press note entitled, “The U.K. Vaping Industry Association [UKVIA] blasts World Health Organization [WHO] and says it risks becoming an ‘enemy of harm reduction.’”

    The UKVIA cannot be described as a militant organization. It has firm ideas, but it prefers to work quietly and closely with the U.K. government, health authorities and anybody else willing to listen to its tale of running businesses that promote tobacco harm reduction while trying to turn a profit. So, the tone of the heading made me sit up.

    What the UKVIA objected to in the first instance was what it described as “[r]ecent recommendations made by the WHO study group on Tobacco Product Regulations that would prohibit electronic nicotine[-delivery] and nonnicotine-delivery systems where the user can control device features and liquid ingredients.”

    On the face of it, I can certainly understand the UKVIA’s concern. Banning such products would be like banning automobiles with accelerator pedals because they could be used to make a vehicle travel at beyond the speed limit or banning glasses because they could be used to mix mind-altering drugs with lemonade.

    It has been said—rightly in my view—that newspapers are organizations that cannot tell the difference between a bicycle accident and a world war. By the same token, it would seem the WHO has become an organization that cannot tell the difference between a pandemic and everyday life—admittedly, life in all its messiness.

    The UKVIA said the WHO had called also for a ban on vaping systems that have a higher “abuse liability” than conventional cigarettes have; systems that, for example, allow the user to control the emission rate of nicotine. In this case, I’m so underwhelmed by the sound of the problem that I can assume only that I have misunderstood what is being said here. Isn’t it the case that nicotine uptake is controlled by the inhaler at a subconscious level?

    In any case, I cannot see what business this is of the WHO. Does it want to micromanage every aspect of the lives of everybody on the planet? Is it going to start looking into the “abuse liability” of high-performance cars, over-proof alcohol and sickly candy bars? Of course, if it wants to make itself useful and if it is happy working at a national rather than a world level, it could end no amount of inflicted harm by helping to do something about the abuse liability and abuse reality of the many and increasing dictatorial regimes around the world.

    Empowered personal choice

    The director general of the UKVIA, John Dunne, believes the WHO poses a threat to smoking cessation and harm reduction in the U.K. “While the WHO is scheduled to hold a crucial summit on vaping in November 2021, known as COP9 [the Conference of the Parties to the WHO Framework Convention on Tobacco Control (FCTC)], it continues to find itself at odds with health and industry advocates,” he was quoted in the press note as saying.

    “Certain WHO positions are now so out of date, and so thoroughly refuted by the experts, that they may as well be saying the earth is flat. They deviate dramatically from leading experts, including Public Health England (PHE) and Action on Smoking and Health …

    John Dunne

    “Take for example vaping helping people to quit smoking, which the WHO says there is ‘little evidence’ of. As early as 2019, clinical trials were finding vaping to be almost twice as effective as nicotine-replacement therapy …

    “Just this month, … PHE … found in its Vaping Evidence Review 2021 that smoking quit rates involving a vaping product were higher than with any other method in every single English region. For the WHO to hold such contrary views is either bad science or bad faith. Both risk it becoming an enemy of harm reduction.”

    Dunne made the point that vaping’s success as an industry, and its potential for public health improvements, were built on empowering personal choice. “Different systems, styles and flavors give consumers the options they need to leave combustible cigarettes behind,” he said. “I would urge the WHO to engage with vapers, to hear their stories and discover the life-changing decisions they’ve made… Prohibition is simply not the answer.”

    The press note also said that the U.K. was due to send a delegation to the COP9 summit later this year, the first time it would be attending such a summit since leaving the EU, and it was to be hoped that this would provide an opportunity for it to promote harm-reduction. In addition, it said the UKVIA had been among expert guests invited by the All-Party Parliamentary Group for Vaping to advise on the COP9 delegation’s approach.

    “The U.K. has a genuine opportunity to promote harm reduction as a valid, progressive strategy for public health on the world stage,” said Dunne. “We must not allow misinformation to undermine this potential, irrespective of the source.”

    It is indeed to be hoped that the U.K. delegation to COP9 can bring a little reason to the table, assuming it gets to the table. From what we of the outer dark can ascertain, however, the FCTC does not brook dissent and, as part of its strategy to avoid it, tends to block the attendance at meetings of those not of the true faith. It will be interesting to observe what it will make of a delegation that has been in direct or indirect contact with a vaping body, assuming the delegation does not cave in and join the happy-clappies.

    Return to sender

    Meanwhile, the UKVIA has a further problem. In another press note in March, it said it was deeply concerned by news that U.K. businesses were being impacted by the U.S.’ “vape mail” ban, part of a congressional spending bill passed under former President Trump. By April 27 [after this report was written], leading carriers, such as UPS, FedEx, DHL and the U.S. Postal Service, were due to be off-limits for vaping shipments.

    FedEx had cited “cigarettes, cigars, loose tobacco, smokeless tobacco, hookah or shisha, vaporizers (and) e-cigarettes” as “tobacco products,” which would no longer be accepted. The UPS said it would prohibit “any and all noncombustible liquid or gel, regardless of the presence of nicotine, capable of being used with or for the consumption of nicotine” as well as “all related vape devices, products and accessories …”

    Again, we find ourselves in a bizarre world. I take it these bans are somebody’s idea of a health and safety policy, but, with more “premature deaths” worldwide attributed to outdoor pollution than to tobacco consumption, logically, the carriers should ban deliveries of everything—they should remove themselves from the roads, the air and the sea. Or there should at least be an acceptance that both tobacco smoke and vehicle pollution are health hazards and that whereas carriers might be trying to lessen the pollution they create by switching to cleaner vehicles, craft and vessels, the tobacco industry is trying to lessen the amount of tobacco smoke by getting consumers to switch to vaping, a task not made any easier by carrier bans. Of course, there is little the carriers can do to reverse this nonsense, but they could at least have a word with any politician ready to listen.

    “The vaping supply chain is a global one, bringing together resources and expertise from around the world,” said Dunne. “It is bitterly disappointing to see these American restrictions having a negative impact in the U.K., but the nature of the supply chain makes it inevitable. In the EU, too, we are hearing of vaping businesses being turned away from major carriers.

    “The potential impact on public health is grave as so many people are relying on shipped goods as a lifeline during the pandemic. Without proper access to harm reduction products, we know people can revert to smoking cigarettes, today in the U.S. but perhaps tomorrow in the U.K. With businesses already struggling through lockdown, and our health services under great strain, supply chain issues really are the last thing we need.

    “I call on the distribution industry, many of whom have been partners of the vaping industry for many years, to do all they can to support their U.K. customers and to avoid the blanket implementation of U.S. restrictions worldwide.

    “Furthermore, I call on the U.K. government to ensure that carriers in this country are free to continue to deliver vaping products to retailers and direct to consumers and to resist any urge to follow the U.S. down this regressive route.”

    I take it that the “vape mail” ban is largely about keeping vaping products out of the hands of young people. It’s a strange thing that the activities of adults, which have always been restricted by the need to guard against criminal activities, are now increasingly becoming restricted by perceived threats to young people—often inappropriately referred to as “children” when it becomes necessary to ramp up the emotional blackmail.

    Credit: Haiberliu

    Such restrictive measures would be acceptable in my view if they were applied across the board, but they are not. Young people are seen by many people in authority as having to be protected against the minuscule threat posed by vaping products while many youngsters are allowed to go hungry, threatening their development and negatively affecting their whole lives.

    It would seem that young people are granted protections when those protections do not inconvenience the majority of voters. See how far you would get trying to introduce a 20-mph speed limit in cities so as to cut the number of deaths and injuries suffered by young people in collisions with cars.

    The Conservative Party, which has been in government in the U.K. for more than 10 years, has a poor record on child poverty, which has shot up under its governance, and on child hunger, in the face of which it twice provided relief for the neediest children during lockdowns only after being shamed into doing so by a campaigning footballer.

    But, on the other hand, it has had a good record in respect of supporting the tobacco harm reduction potential of vaping, and the UKVIA is hoping the situation in the U.K. can be improved further following the country’s exit from the EU.

    On March 15, the UKVIA launched its Blueprint for Better Regulation in response to the U.K. government’s consultation on the Tobacco and Related Products Regulations (TRPR) (and the Standardized Packaging of Tobacco Products Regulations), in which it was seeking until March 19 feedback on the effectiveness of the legislation in achieving its objectives and any unintended consequences that may have occurred.

    In a foreword to the blueprint, Dunne said the review of the regulations represented a defining moment in the history of the vaping industry, one of the leading market disruptors in the 21st century responsible for a significant decline in smoking across the U.K. It also presented the biggest opportunity yet for the government to create fair and proportionate vaping regulation that supported its 2030 smoke-free target and ensured the sector could make a bigger contribution to the nation’s public health and economy in the future.

    To achieve such a goal, the UKVIA needs the help of the government to counter the misinformation currently providing an increasingly powerful drag on efforts to encourage people to switch from smoking to vaping. It needs the government’s help in mounting promotional campaigns aimed at such switching, and its permission to mount its own agreed consumer communication campaigns, including with those buying online. And it needs the freedom in which its members can develop vaping products capable of competing with conventional cigarettes on a nicotine-satisfaction basis.

    There is, of course, much more in the UKVIA’s blueprint. No such presentation would be complete without a discussion of the important role flavors play in encouraging people to switch. The blueprint looks at packaging and labeling, descriptors and product quality and safety. It supports age restrictions on the purchase of vaping products and the need to work with trading standards officers in ensuring such restrictions are enforced. And it wants the government to act in relation to vaping in public places.

    What are the chances? Well, Dunne appears to be confident, and, as is mentioned above, the government has in the past been supportive of the tobacco harm reduction argument made in respect of vaping; so it could be willing to work with at least some the UKVIA’s ideas, perhaps all of them. But caution must be advised.

    Two skills the U.K. government is known for are its shape-shifting and U-turns. And one concern must be the government’s likely reaction if it found that conversions to vaping picked up so fast that tax revenues from tobacco fell dramatically. It’s addicted to such revenue, especially since the promised Brexit dividend, not even mentioned in March’s budget, seems to have melted away.

  • Thrown Under the Bus

    Thrown Under the Bus

    London double bus
    Credit: Albrecht Fietz

    If society wants a smoke-free world, it cannot allow promising products to die of neglect.

    By George Gay

    Browsing the internet recently, I came across a report claiming that 22 countries with, according to my calculation, a total population of about 2.6 billion, or 34 percent, of the worldwide population, had banned the use of vaping products. I cannot vouch for the accuracy of those figures, but I guess they would be at least as accurate as the widely accepted estimates of worldwide, annual tobacco-related deaths.

    At the same time, many people are living in countries where certain forms of vaping products are banned (Japan, for example, with a population of about 126 million) or where the appeal of vaping products has been deliberately and sometimes severely narrowed by, for instance, restricting flavors (the U.S., 328 million) or limiting nicotine levels (countries of the EU, 448 million post-Brexit).

    Looking at this situation, I couldn’t help wondering whether a person with the foresight 15 years ago to have predicted the arrival on the market of products whose consumption was far less risky than was the consumption of combustible cigarettes and that could substitute for those cigarettes would have foreseen also the wide-ranging and often visceral hostility that has greeted their arrival.

    I can’t help feeling that our seer would have dismissed as ridiculous the idea that these new products, vaping devices as it turned out, would be so badly served by so many governments, companies, organizations and individuals. She would surely have found it incomprehensible that smokers would be let down so badly.

    Why? Well, as is still the case, 15 years ago, the combustible cigarette was the pariah consumer product and, we were told, no amount of effort was being spared in trying to do away with it. It was claimed that this was the only product that killed its consumers when used as it was designed to be used, and this claim was employed to underpin the justification for legislating for the degradation of both the product and its packaging, and the restriction of cigarette sales.

    man holding up hand stop
    Credit: Nadine Shaabana

    And it was not only the product that was seen as unacceptable. Cigarette manufacturers had cynically manipulated their products to make them “more addictive” and thereby keep consumers hooked and the profits rolling in. And consumers were little better. So, in the U.K. at least, they were attacked by officialdom as being smelly and then denormalized to the point where they and their secondhand smoke were cut off from normal society.

    Given this, and given that vaping is recognized by most sensible people to be hugely less risky than is smoking, why is it that vaping has had such a rough ride? There are, of course, any number of reasons based on the vested interests and breath-taking hypocrisy of some individuals, researchers, companies, organizations and governments, for all of whom and which the continued use of tobacco represents a nice little earner.

    But here I would like to speculate about another possible reason. Could the U.K. government at least have decided that the problem of tobacco smoking has been overblown? No, let me put that another way. Could it be that the government has decided that the net problem caused by smoking—that is, the smoking negatives minus the smoking positives—has been overblown, especially when compared with other problems it must confront? For instance, I guess it is becoming just too difficult to ignore the elephant in the morgue: the pollution-related deaths, many of which, I assume, overlap with tobacco-related deaths.

    According to Damian Carrington, environment editor, writing in the Guardian on Jan. 26, a global review in 2019 concluded that air pollution may be damaging every organ in the human body as inhaled particles travel around it and cause inflammation. And it is instructive, I think, that a statement made late last year by the U.N. secretary general, Antonio Guterres, pointing out that air pollution is killing nine million people a year, has, unusually, not been trumped by the World Health Organization coming up with an even higher figure for tobacco-related deaths.

    But I have a more specific reason for believing that the U.K. government might be letting smoking slip down its list of priorities. While it has been progressive in respect of encouraging the use of vaping as a means of getting people to quit smoking, during the Covid-19 pandemic, it has steadfastly refused to allow vape shops to open during lockdowns; that is, it has deemed them not to be essential, whereas a shop selling plugs for the basin in your bathroom apparently is essential. This indicates to me that the government doesn’t put much importance on encouraging people to quit smoking, though that is not to say it isn’t happy to dabble in such an enterprise.

    OK, I hear you ask, could it be that the government does believe that encouraging people to quit smoking is important, but, right now, in the face of a deadly pandemic, such encouragement has had to take a back seat?

    There are a number of reasons why I don’t think this is the case. One is that the government has found the time to deal with all manner of pet issues during the pandemic, such as its undermining of the BBC in an attempt to better control its image. Another was Brexit, which was hugely time-consuming, but its deadline our erstwhile fellow members of the EU had been willing to postpone.

    However, the most telling reason in my view was the government’s announcement at the end of March 2020 that it was to axe Public Health England, an executive agency of the department of health and social care, and transfer some of its responsibilities, but not its smoking prevention and some other obligations, to a new organization, the National Institute for Health Protection.

    Meanwhile, while the government seems to be taking its foot off the quit-smoking pedal, there are some for whom the very existence of the pandemic is seen as underlining the need for the government to encourage the switch from smoking to vaping. The usual suspects have been only too willing to tell smokers, without, I suspect, any solid evidence, that they are at increased risk of suffering severe symptoms if they are infected with Covid-19. And one respected public health professional has argued that the emphasis should be placed on fighting noncommunicable health problems because, in that way, we will all be leaner and fitter to fight the next pandemic. Hmm.

    I cannot agree with these people’s reasoning, but I do maintain that this is not the time to let the opportunities offered by new generation products slip through our fingers. And in this regard, I would like to put in a word for Kind Consumer and Voke, whose fortunes I have followed on and off for a number of years. Voke, as I wrote about last year, is a product that was developed by Kind and licensed by the U.K. Medicines and Healthcare products Regulatory Agency as a medicinal product that is a safer alternative to smoking. Voke is not a vaping product but an alternative nicotine-delivery system that uses pharmaceutical-standard inhaler technology in a device that closely resembles a traditional cigarette in both the way it looks and in the way a consumer, in using the device, mimics most of the rituals of smoking.

    Voke, which has no batteries and no electronics and therefore generates no heat and no chemical reactions, produces no smoke nor vapor, just an invisible, odorless aerosol, so it can be used anywhere. And its environmental credentials are good given that it is a relatively simple device made of metal, card and plastic: materials that can be recycled.

    Last year, I wrote that, in theory at least, Voke should be a game-changer and that it would be interesting to follow its fortunes on the market to discover how committed smokers and vapers were to the pursuit of reduced risk.

    I’m now concerned that I may never know. Voke was launched in November 2019 exclusively online, but when I visited the Voke website in January this year, this is what I was told: “Due to Covid-19 and the current financial climate, we are unable to accept any orders.”
    Meanwhile, a Sky news story toward the end of last year said it was understood that Kind, which had raised £140 million from investors since it was set up [in 2006], had, at the beginning of December, called in the administrators and that they had signed off on the sale of Kind’s assets to OBG Consumer Scientific, a subsidiary of Pharmaserve, a privately owned group, for £1.6 million.

    Pharmaserve, which is based in Runcorn, U.K., did not respond to requests for information, so I am unaware of what fate awaits Voke. However, one source told me that Pharmaserve had been part of the Voke supply chain, providing the device’s cannisters, and this aligns with information provided by Kind, which said last year that one of two manufacturing sites it was using was at Runcorn (the other was said to be at Waterford in Ireland). If this is the case, it is quite possible that the product will be relaunched.

    It would certainly be a crime if Voke were allowed to disappear without fully testing whether it can become a game-changer. There is no doubt that, because it delivers a cool aerosol rather than a warm vapor, it presents a challenge to smokers wishing to switch. But, at the same time, its nicotine delivery is efficient enough that it has to deliver only a low dose, 0.45 mg, from which, if the U.S. Food and Drug Administration is correct, it could be inferred that it creates a significantly lower risk of sustaining addiction than do cigarettes or e-cigarettes.

    And Voke seems to have some as-yet untested advantages over cigarettes and electronic cigarettes when it comes to sales channels. While the product had a medicines license that allowed it to be prescribed by a doctor in the U.K., it had also an over-the-counter drug or general sales list label, so it could have been sold anywhere from pharmacies to major retailers, corner shops and garage forecourts. And there was no reason why Voke, under another name and possibly modified, could not be sold in other jurisdictions simply as a consumer product.

    Many societies that claim they want to become smoke-free have thrown obstacle after obstacle into the path of vaping devices. Surely, we are not going to let Voke fail for the want of a little investment. According to the Sky story, Kind had been looking to raise only another £36 million to deliver a revised business plan, so here, perhaps, was an opportunity for a tobacco company—or even the U.K. government.

    man breaking cigarette
    Credit: Martin Budenbender

    Of course, the U.K. government is ideologically opposed to public involvement in the private sphere, but there were some good reasons why it could have justified keeping Kind and Voke going. I don’t know why Kind got to the point where it had to call in the administrators, but certainly, fate had not been kind to it. When, in 2009, Kind set out in earnest on the development of Voke, it immediately found itself in a commercial bind.

    At that time, when vaping devices were still something of a novelty, it was believed that, under the then forthcoming revised EU Tobacco Products Directive, all such products sold in the EU would need to have a medicines license. But such a requirement fell by the wayside; so Voke, a device being developed at great expense within the constraints necessary to make it conform with a medicines license, was destined to compete with devices developed at less expense without such constraints. And to cap it all, Voke was launched just as the world was hit by the start of the coronavirus pandemic.

    If societies believe that tobacco smoking is as harmful as it is generally made out to be, and if they are truly aiming to go smoke-free, they cannot afford to allow the army of naysayers to keep throwing vaping devices under the bus, and they certainly cannot allow a promising product to die of neglect.

  • Eyes on the Prize

    Eyes on the Prize

    no smoking
    Credit: Tumisu

    While tobacco harm reduction products have an important role to play, quitting ‘cold turkey’ remains a legitimate strategy in pursuit of better health.

    By George Gay

    According to a joke included at the end of a London Review of Books piece by Jerry Fodor, a keynote speaker opens his remarks at a philosophical conference by saying that, in principle, there are 12 philosophical positions, only to be interrupted by a heckler shouting, “13!” The keynote speaker continues: “As I was saying, there are 12 philosophical positions …” but again the heckler shouts, “13!” The speaker then says that he will describe briefly the 12 philosophical positions. The first, he says, is Naive Realism, according to which things are more or less the way they seem to be. At that point, the heckler shouts, “Oh no, 14!”

    You don’t have to be a philosopher to get the message that there is a danger that complexity can suffocate simplicity and the common-sense benefits that the latter has to offer. This isn’t to say there is no need for complexity—just that there is also a need, at times, for simplicity. As I believe Einstein once put it: Things should be made as simple as possible but no simpler.

    Is there not a danger that in pursuing tobacco harm reduction (THR) we are losing sight of the simple? I know it’s unfashionable to ask, but what is wrong with smokers going cold turkey if they want to quit their habit? There was a time when all smokers who wanted to quit went cold turkey because that was the only route out of tobacco. And millions did it. I was one of them.

    What a lot of readers will be thinking, however, is that there’s nothing stopping smokers from going cold turkey, so what’s the problem? Well it’s not quite true that there’s nothing stopping them doing so. I can think of at least two things that would be holding them back.
    One is the fact that various people and organizations have taken a lot of trouble to convince smokers that quitting cold turkey is incredibly difficult, if not impossible. They have tried and largely succeeded in convincing many smokers that they are victims who cannot control their own destiny. Their ability to make decisions about smoking and health has been taken from them by tobacco manufacturers. This, of course, is nonsense, but it is a useful narrative for some people to spread and, regrettably, for others not to counter.

    The other reason is that smokers are given too little help to quit cold turkey. Why couldn’t a large part of THR comprise tobacco tax-funded public announcements encouraging smokers to quit? Of course, there would be a need firstly to sound a very loud warning bell.
    Such announcements should not descend into the type of propaganda beloved of certain governments and organizations where smokers are depicted as being victims of the tobacco industry, patients of the medical profession and the scourge of society. And such announcements should not feed smokers a bunch of lies and half-truths, try to frighten the pants off them and generally treat them as though they were children without the ability to make rational decisions.

    Better still, smokers should be provided with positive rather than negative information. They should be told how quickly, post-quitting, their risk of contracting certain diseases and conditions falls to that of, or near to that of, nonsmokers. And they should be told how, in quitting smoking, and especially in quitting cold turkey, they will be saving money while making a positive contribution to helping prevent pollution and the further degradation of the environment.

    One of the problems is that THR has become monetized—become part of the destructive system under which the worth of everything is judged by its performance on the “market.” We have been fooled into believing that what matters is that smoking is replaced by something that can be sold, preferably for the same sorts of profits that are currently enjoyed in selling cigarettes. That is, cigarettes have to be replaced by less risky tobacco and nicotine products, including nicotine-replacement therapy products manufactured by the pharmaceutical industry.

    And it is true that there would be something to be said for such a way of looking at smoking cessation if it weren’t for the fact that less-risky products seem to be struggling—entangled in endless debates based on science and pseudo-science, conspiracy theories, political shenanigans and great dollops of bureaucracy.
    These debates are all very interesting and take up hours of conference time, but they remain largely unresolved, like Fodor’s philosophical positions two through 12, and they simply leave smokers up a creek without a paddle. The interests of the smoker seem to have been pushed into the background as the various sides in the THR debate defend their own positions and brief against each other.

    That something is seriously wrong with efforts being made to promote smoking cessation is clear from Burning Issues: Global State of Tobacco Harm Reduction 2020, the second (the first appeared in 2018) such report written by Harry Shapiro and published by Knowledge-Action-Change. This 162-page report makes the point that after more than a decade of product availability, there are only nine users of “safer nicotine products” (SNP—vapor devices and heated-tobacco devices, Swedish style snus and some other safer forms of smokeless tobacco) for every 100 smokers.

    This should sound alarm bells, and it does, but those bells are peeling out the wrong message as far as I can hear. They are calling for more of the same. How does it go? Having lost sight of our objectives, we redoubled our efforts.

    I should add, however, that this is an excellent report with masses of information about where we are with THR and the SNPs that underpin it and how we got here. The way forward is less clear because it is difficult to navigate a path in the face of the guerrilla activities employed by those opposed to the THR approach—activities that have so far proved fatally successful in casting doubts in the minds of smokers and vapers. Nevertheless, the report contains 15 recommendations (as well as 20 conclusions) that map out a route to the future. Though, in the light of the short history of THR, some of those recommendations might better be described as wishful thinking.

    One of the things that becomes clear in the report is how little success had been achieved in pushing the quit-smoking agenda before the incorporation of the sorts of harm reduction principles that had already been well established in respect of other health challenges. And little wonder given that pre-THR, the approach had been to bully smokers into quitting. THR takes an altogether more humane approach, as the report spells out:
    “Harm reduction refers to a range of pragmatic policies, regulations and actions, which either reduce health risks by providing safer forms of products or substances, or encourage less risky behaviors. Harm reduction does not focus primarily on the eradication of products or behaviors.”

    Contrast this with the methods employed before THR and that are still pushed by many governments, organizations and individuals—methods that are based on discouragement or punishment. Such methods include the degradation of the products that smokers enjoy through pointless controls on nicotine levels, the banning of harmless flavors and the despoiling of packaging. They include the inexcusable use of smoker “denormalization” or officially sanctioned discrimination. And they include the imposition of grossly unfair levels of taxation.

    guy vaping
    Credit : Omni Matryx

    Meanwhile, there are issues brought up in the report that I believe could usefully be subjected to further analysis in any forthcoming edition of Burning Issues. The report mentions that the World Health Organization (WHO) has “not revised downwards its estimate that one billion lives could be lost to smoking-related disease by the end of the century.”

    Despite the fact that many of us are highly critical of the WHO’s attempts at encouraging smoking cessation, we tend to accept its figures unquestioningly. But whereas, for instance, a figure of one billion is convenient to throw about, when you think about it, it is ludicrously rounded. And given that this is a worldwide figure, you have to ask yourself how the data are gathered in many countries, especially in those where, perhaps because of wars, there are no fully functioning administrations.

    And it would be good to see some of the methodologies used in compiling such figures. Since, I guess, some people die of “tobacco-related diseases” that might also be seen as “pollution-related diseases,” how are these deaths divided up? I suspect that the default setting is to put such deaths into the tobacco-related deaths column, in which case the WHO’s tobacco-related deaths figures are likely to be inflated.

    This is not an attempt to get tobacco partly off the hook but to make sure that we are taking action where action is required and not just where some people would like to see it applied. There is no point in developing vapor devices if the disease problem is down to the pollution caused by air travel, etc.

    But what I would like to see, especially, is detailed information on how “tobacco-related” diseases and deaths have fallen with the reduction in smoking in those countries where such smoking reductions have occurred. In countries such as the U.K., smoking has been falling long enough for the related diseases to be also showing declines, and there should be a recognizable correspondence between the two.

    lady vaping
    Credit: Kjerstin Michaela Haraldsen

    The problem with accepting blind what the WHO has to say is that one can end up being mesmerized by huge figures and drawing some questionable conclusions. The report states, for instance, that the one billion tobacco-related deaths “[are] equivalent to the combined populations of Indonesia, Brazil, Nigeria, Bangladesh and the Philippines dying from Covid-19.” I know that it is considered rather trite to say so, but shit happens, people die, and it is necessary to keep a sense of proportion.

    If you look at a long enough time frame, you could probably say that the equivalent of the population of Belgium will die from having pieces of toffee stuck in their windpipes. And I think the reference to Covid-19 doesn’t stack up.

    There is a world of difference between smoking and Covid-19. A lot of people won’t agree with me here, but people have a choice about whether or not they smoke. But the ordinary person in the street has next to no control over the rise and spread of viruses. That is why, to my way of thinking, viruses are a valid area of interest for the WHO whereas smoking is not.
    I’m not saying that we should row back from THR products, but, at the same time as we are improving these products and making them available, we should be putting our foot down harder on the cold turkey pedal just in case those opposed to THR win the day. It’s not just me being pessimistic. This is from the report.

    As the environment for THR has grown ever more toxic since our last report, we have turned our attention this time to the mechanisms of the well-orchestrated and well-funded global campaigning driving an increasingly prohibitionist response to SNP.
    Despite the above, it is claimed in the report that SNPs have been “disruptive” and that they have provided one of the most startling public health success stories of modern times, claims that, given the slow conversion rate from smoking to using SNPs, seem not to be supported by the evidence. Or perhaps I’m looking at things from the wrong direction. This, too, is from the report:

    “Globally, the value of the vaping market has continued to grow since our 2018 report and is projected to grow further. The chart from Statista43 shows the value of the e-cigarette market at around $19 billion and its steady projected growth from 2012 through to 2023.”
    I see. So it is about monetization, is it? OK, we have to be practical. We have to allow companies to make money, but there’s clearly a problem here. Declines in smoking predated the arrival of SNPs in many of the countries where these sorts of products are affordable, basically the West, but smoking is still on the increase in many low-income and middle-income countries where they are less affordable. If we are not careful, THR will become a system that helps to underpin health inequalities. If you’re rich, you can afford the products to keep you healthy; if you are not … well, too bad.

    By all means, let’s redouble our efforts, but let’s make sure we’re still focused on the goal of encouraging people to stop smoking. We might need to look for new ways of doing this or even old ways, such as cold turkey.