Some observations from Clive Bates ( Public Health England says truthful realistic things about e-cigarettes « The counterfactual ) :
On the 95% risk reduction… this should be seen as a worst case and cautious claim based on current knowledge. There is currently no identified serious health risk associated with vaping, so it is best to see the residual 5% risk as an allowance for uncertainty. The claim for a 95% risk reduction is necessarily an expert judgement on the part of the authors, but their reason for optimism is down to what is known of the chemical constituents of e-cigarette vapour. Most of the constituents of cigarette smoke that are thought to cause harm are either not present in vapour or present at levels well below one twentieth of that in cigarette smoke. The physical basis for the claim is multiple studies of vapour toxicity.
On the corrective to inaccurate risk perception… PHE and many others have been increasingly concerned that the perception of e-cigarette risk compared to smoking is way out of line with reality, and seems to be getting more out of line as the evidence of relative safety strengthens – many scare stories and baseless moral panics have contributed to this, and may be having the effect of putting smokers off trying e-cigarettes and so continuing to smoke. The 2015 ASH Smokefree GB adult survey showed only 52% thought they were less harmful – but even this group don’t necessarily have accurate perceptions of h
ow much less harmful. A responsible public health body tries to align public risk perception with actual risk to the extent possible – and this is the point of PHE making a bold simple to understand claim about the relative risk. The alternative is to let smokers form their own perceptions from news stories and media academics determined to demonise the products – all the evidence suggest this approach leads people to greatly overstate risks. A responsible public body does its best to give people a realistic and understandable anchor for making behavioural choices. A good working assumption is that vaping is not entirely safe, likely to be 95% less risky than smoking, but may ultimately prove to have no mortal risks.
On risks to bystanders… the review follows all the main assessments to date and shows no material risks to bystanders from airborne nicotine or other vapour constituents. Risk to bystanders would normally be the justification for laws to control vaping in public places. But in the absence of risk the issue become one of etiquette for vapers, choice for owners and managers of premises to create the atmosphere and clientele they want, and consideration of the wider health implications of allowing or not allowing vaping in a particular public place. For example does allowing vaping encourage smokers to switch, does banning it encourage vapers to relapse? The government in England is right to think this way and has no plans to use the force of law to ban vaping. On the other hand, the Welsh Government’s proposal to use the law to ban vaping in all public places is an excessive authoritarian intervention that lacks an ethical basis and will do more harm to health than good.
On medicalisation of vaping… the vaping phenomenon is best understood as a market-based transformation of the recreational nicotine market in a way that is good for health – hopefully leading to a substantial shift away from smoking and into vaping. It should be seen as a mass-market alternative to smoking rather than as a treatment for a condition in which a smoker presents to a public health agency with a harm-causing addictive condition seeking a cure. That may sound pedantic, but getting the policy framework right will depend on policy-makers having a realistic grasp of how the benefits come about. That is not to say that NHS, GPs, Stop Smoking Services and public health organisations should ignore them – just that they shouldn’t see it as another form of NRT or Champix. If they want to advise smokers on these products they will need to compete with the expertise available on dozens of forums and be credible experts with smokers. Most of the public sector is way behind the curve on this.
On the shift away from ‘if all else fails’… much of the public sector discussion of e-cigarettes as alternatives to smoking has tended to see them as a last resort to be tried if all other options have failed. This new package appears to provide a welcome change from that – stressing the interests of smokers in finding options that work for them. Also, it’s difficult for the public sector to maintain the ‘if all else fails’ approach while they are providing charts showing high levels of comparative success among those choosing vaping products – as below.
Support used and stop smoking service self-reported quit rates
Emphasis and annotation in dark red added
On the Stop Smoking Services… as you might expect from a public sector public health body, PHE places a lot of emphasis on what role the public sector plays – i.e. through Stop Smoking Services. It is often claimed that the best results come from behavioural support combined with pharmacotherapy of some sort. That might be true, but it addresses a particular subset of smokers – those willing to go to services and complete a behavioural course. Many of the Stop Smoking Services have let themselves down by going into opposition against this bottom-up approach to quitting smoking, but that is now starting to change, with pioneering work in Leicester and the North East and many others adapting to the real world. For me the key role of the public sector is to provide truthful reliable information to those who want it, and encouragement to try this approach to quitting – whether a government web site, a local authority public health programme, a GP surgery or a dedicated Stop Smoking Service. The PHE evidence reports are probably the most important thing the public sector does, because they affect the behaviour of all other actors.
On prescribing e-cigarettes… much of the press coverage picked up on the idea of prescribing e-cigarettes (i.e. making the available free via smoking cessation services). I think this should be downplayed and the normal expectation should be that people will buy e-cigarettes with their own money and from savings made in quitting or reducing smoking. The excise regime should support that. We need to see this a market-based solution (like snus in Scandinavia) and work on the basis that markets will provide the necessary innovation and affordable quality products if not over-regulated. It is not necessary for every problem in society to be addressed with public sector interventions and public spending. As Sir Jeremy Heywood, the UK’s most senior civil servant, puts it in his
blog on e-cigarettes:
It’s easy to think that the solution to a policy problem is to fund a new programme or put in place new legislation. These are, of course, important parts of a policymaker’s toolkit, but new approaches can often help us to solve the problems that we face.
Where I have been persuaded (by Linda Bauld and Deborah Arnott) that some intervention is justified is in helping the poorest smokers to get started on vaping. If you are a smoker on a very tight weekly budget, then the economics of a switch to vaping can look daunting – there are
upfront startup costs to get to the better tank/mod products (which are then much cheaper overall) and you might be concerned that you’ll try e-cigarettes, they won’t work and you’ll have to buy the cigarettes as well. So for health inequalities reasons there may be a case to assist low-income smokers in making a transition. But for me, that’s all. It shouldn’t be a routine call on the public purse. It’s good to have health interventions where no taxpayers are harmed.
On medically licensed e-cigarettes… I think that the distinction between licensed and unlicensed nicotine products is unhelpful and a distraction in policy terms. The medicines regulatory regime is so burdensome, restrictive and expensive that it cannot be assumed that the products that pass through it will be better for smokers – they are more likely to be designed to meet regulatory requirements than to meet actual smokers’ needs. The example of NRT should serve as a warning: ‘licensed’ doesn’t mean ‘better’. The Tobacco Products Directive is
useless, but the logical approach would be to allow any products that are compliant with that regime to be used in publicly funded programmes. In the post-TPD world, medicines licensing may have some advantages to the bigger tobacco-owned vendors who can bear the compliance costs – lower tax, advertising allowed, more proportionate warnings etc. But these advantages arise primarily from the failure of the TPD to provide a sensible regulatory regime for e-cigarettes rather than any safety, quality or efficacy benefits to the consumer.
On the Tobacco Products Directive Article 20 – this is a
truly dreadful piece of legislation, made in haste on the foundations of bad science, bad economics, bad ethics and bad process. If this evidence review had been available during the negotiations we might have better legislation – but instead of taking care to get this right and save thousands of European lives, the European legislature just blundered on full of hubris and anti-scientific delusions. The directive was based on junk science from WHO (
here and
here) and negligence on the part of the European Parliament rapporteur (
here), evidence free ideas of the European Commission (
here) and the unrivalled pomposity and negligence of the European Council and its Irish presidency along with many other actors (
here). I really do hope lessons are learned.
On the messages for others… Public Health England has done what a good public health body should do – looked at the evidence, thought about its responsibilities and worked through how to bring evidence into policy and practice. How many of its peers in other countries can claim the same? Where is the equivalent analysis from CDC or the extremists in California? What do Australia and Canada have to back their prohibitionist positions? When will WHO start to act as though e-cigarettes are part of the solution, not part of the problem? What messages will Gates, Bloomberg and Soros take from this? Why does CTFK decline to do what the much more modestly funded ASH does in the UK? Where are the open minds in cancer, heart and respiratory charities and societies? The message for others is simple: stop believing the rhetoric of prohibitionist activists and anti-corporate campaigners and take a cool hard look at what is really going on and what the evidence tells you – then act accordingly.
