Updates by Dr. Carl Phillips from Europe SRNT Conference

[Vocalek]

Dr. Phillips is blogging about his experience at the European conference of the Society for Research on Nicotine and tobacco (SRNT) in a Discussion area on the CASAA Facebook page.

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For those of you not on Facebook, here is a copy of his latest entry:

Carl Phillips
A few random observations:

We are all familiar with zealous anti-tobacco messages, and sketchy assertions about what is ethical, what motivates people, etc. But as nutty as the ANTZ messages are, at least there is something honest about presenting the messages overtly. There is something that is more disturbing about burying the same premises in a scientific analysis. But I guess it is not surprising that I am sensitive to that, since it is kind of what my talk focuses on.

Talked with some colleagues from Sweden about their research (all the evidence suggests dual snus-smoking does not prolong smoking) and other topics. Interesting story about how a research team in Sweden broke off collaboration with Swedish government because they (the govt) insisted on getting all the raw data so they could figure out how to analyze it so that it supported their extremist policies. Shared observation: There seems to be infinite money to abuse mice to draw bio-chem conclusions about nicotine, but we cannot figure out how to get funding to do the research about human preferences and motives that might actually be useful.

Great talk title: "Are there unintended consequences of smoke-free legislation on stigmatization...." My answer: no -- the stigmatization is all intended.

Presentation by Maciej Goniewicz (in one of the natural science sessions): Testing of e-cig cartridges and refill found that nicotine content for about 1/3 differed from label by >20% (carts were worse). No info on which suppliers, like whether these are major suppliers or are respected in the vaping community; it would be more useful to know the results for good-reputation suppliers.

My brain finally thinks it is time to wake up -- just in time for my session.

 

[Vocalek]

Here is another one:

Carl Phillips

Sadly, due to the flight problems, I missed the keynote from Robert West, "Using Theory to Design Better Tobacco Control Interventions". The name sound like the same old stuff, but the abstract showed more of interest -- I will post it when I can.

The plenary this morning was Marina Picciotto talking about nicotine receptors in mice. I don't read too much of that end of things, so it is periodically useful to be reminded about how common this perspective is. In philosophy of science there is awareness that sciences are subject reductionism (sociology can be reduced to microeconomics, can be reduced to neurobiology, can be reduced to electromagnetism), and a recognition that just because something can be reduced to a "harder" science does not mean that it is particularly useful to do that. We can undoubtedly learn useful lessons about human welfare from looking at neurological receptors, but the attitude is basically that we can replace our attention toward human welfare per se with attention to biology.

 

[Vocalek]

And another:

Carl Phillips

Our session on e-cigarettes went very well. I will probably need a few posts to capture everything, starting with this one.

It was the best-attended session of the day, by far, and the audience was much more attentive than is typical for one of these conferences. So it is definitely the hot topic of the year (no surprise there, of course).

JF Etter started with an introduction and concluded with a research agenda (which differs some from my proposed research agenda, but is mostly the same). Riccardo Polosa summarized some of the clinical-type research about e-cigarettes being a satisfying substitute, introducing some of the new research on the topic. Big surprise (-sarcasm alert-) from the new research: e-cigarettes deliver plenty of nicotine. Maciej Goniewicz summarized the surveys of users and presented other information about the social phenomenon.

I presented my case for what research is useful and not useful (or harmful). Rather than try to summarize, here is the final version of my slides: https://docs.google.com/viewer?a=v&...NjRkYS00NjQxLWEwMGUtZWFjZjIxNDIzODhm&hl=en_US

 

[Vocalek]

Hot off the presses:

Carl Phillips

Lots of people were very interested in the e-cig session and commended one or more of us for it. Some people clearly did not get it, though. I found it sadly amusing when someone, during the questions, asked about pharmacokinetic testing and there was a brief flurry of responses, including one from the floor from Karl Fagerstrom about particle size and lack of lung deposition. I put an end to that line by repeating my point, that might have been a bit subtle in the talk, that such research is kind of like doing a study of how fast computers are: you can certainly do it, and it might provide an interesting baseline someday, but frankly it does not matter much because it depends on the specific tech being tested, and that tech will undoubtedly be replaced soon. Right after I said that, the very next follow up basically called for the same research again.

Give some people a hammer and there is no point in trying to explain that it accomplishes very little to pound this particular nail. (Indeed, it is probably even worse than that: If someone does one lousy study of something like that using one particular c2011 product, people are going to be declaring that its results are a universal truth for five or ten years. So it might actually be harmful for someone to do it.)

Someone else was pushing me to declare an opinion about whether any regulation might be good and about rules about health claims. I said that my opinion (speaking just for myself) was that quality control regulation would be great, but there was a lot of risk of it being prohibitionism in disguise. As for health claims, I suggested that it would be just fine if every manufacturer and merchant was banned from making any health claims, given that most players in the industry are not qualified to do so anyway, and just create informational pollution on average. I passed on offering an opinion about what might justify regulation as a medicine or some such -- it is hard to give a concise answer to that given that I find the premise so wrong.

Following up on that theme, Maciej and I were talking afterward, and he was pushing the point that regulation for basic quality -- like food safety regulation -- is clearly a good thing, perhaps for the purpose of suggesting to me that I should be more positive about regulation. That led me to an interesting point that I will introduce here and definitely should use again: Consider regulation of a restaurant. We all want it to be the case that there is regulation about food handling, hygiene, truth in labeling, and such. But it would be a disaster if the government had to sign off on every menu change and recipe. That is not only meddling in free market choices that should not be regulated, but it would eliminate innovation and pretty much destroy good restaurants. But so far, no government -- except possibly New Zealand, according to one conversation I had, but that is another story -- seems to be willing to regulate just the legitimate part (quality control, labeling) without trying to micromanage the menu (requiring some kind of application and approval for every product). Better nothing than that.

 

[Luisa]

Hot off the presses:

Thank you for posting this information.

 

[Vocalek]

Posted 10 hours ago:

Carl Phillips

The current session on smokeless tobacco seems to be the second-most popular of the conference (though a lot less than our e-cigarette session, where people were spilling out the door).

Dorothy Hatsukami reported some research she has been reporting for a year, on a snus and Star lozenge based smoking cessation trial. The results show pretty good effectiveness given the artificiality of the experience. She tried to make a big deal about the differences between products (Camel Snus did a bit better than other options), though she seems oblivious to random error (she was making claims based on a fairly small sample when the confidence intervals would have totally overlapped -- if she had bothered to report confidence intervals). Tom Wikmans, who I am sitting with, and I had a quick sidebar about the fact that no one in the trial chose the large pouch General, which was an option, only the American products; it might have been a more effective smoking cessation option, being higher in nicotine, but is not so appealing to just start using. The absence of the ability to switch products and especially no expert coaching ("you may like this tiny minty product initially, but we know you are more likely to succeed in quitting smoking if you use this other product") makes the methodology a bit of a joke.

Another newer study she reported compared snus to NRT gum, and found little difference in smoking cessation. But it was a very short term and few of the participants even used much of the smokeless products, so the intervention method itself was pretty much a failure -- not that this will be the conclusion when the study is published, of course.

 

[Vocalek]

Posted 9 hours ago:

Carl Phillips

Karl Fagerstrom also presented the results of a clinic intervention for snus-based smoking cessation. Unlike DH, he actually discussed why anyone would do such a thing: because, despite the impressive evidence in other forms, certain people insist on saying that a trial is needed. He did not comment that this was a dumb failure to understand science -- apparently he does not agree with that point, since he participated in the study (which I refused to do, on principle). The trial he participated in compared snus to de-nicotinized snus, which is kind of a weird comparison. The results were really poor (little snus use, little cessation, though definitely more with nicotine), which he reasonably attributes to doing the study at a CRO that does not do smoking cessation therapy and just recruits people who want to be paid to be in studies (ie not volunteers who are interested in quitting). Imagine getting handed THR products and half-assed advice at the lab you would go to if you needed an shoulder x-ray.

This is a great illustration of how stupid the notion is that randomized clinical trials are a source of better information than observing the real world.

Carl Phillips

David Levy just made the observation, from the floor, that implicitly pointed out that these comparisons of different products are kind of stupid (my interp, not his words) because one product might work for one person and another for others. He called for the studies to compare people who choose particular options I obviously agree with this.

Also, it occurs to me that this obsession with clinical trials is kind of like a joke that is made about economists, observing that they have a proclivity for observing something occurring in practice and set out to see if it works in theory.

Kathy Backinger (sp?) from FDA was making comments from the floor about what claims US smokeless makers can make about THR: submit data to FDA, blah blah. Then she complained(?) that marketing focuses on the "when you cannot smoke message". Well duh! she just said that her shop bans them from saying anything else. This is just so absurd. How can they claim with a straight face that someone needs to submit data to show that smokeless is lower risk than smoking?

Carl Phillip

Where is all of this Turkish coffee I have heard so much about? In typical Euro fashion, they serve nothing but Nescafe at this hotel. I have been mixing up Starbucks Via. Don't ever let anyone tell you otherwise: The USA is the home of the most reliably good coffee in the world.

Sorry, I'll get back on topic now.

Carl Phillips

Finishing up on the ST session: Heb Severson presented about their quit-snus website study, which found no difference in quitting among those who were randomized to the simple static advice site and those in the fancy interactive and tailored one. What he and discussant Ed Lichtenstein both seemed to overlook is that the quit rate might have been about the same as either of these without a website -- recruiting young people who are actively seeking to quit ST is going to yield a lot of people who will quit soon no matter what.

After several people, including in particular Backinger, made comments about us (ie Americans) not having data about switching, dual use, and such yet. We do, of course. But even more annoying (as noted by Tom), there is a lot of evidence from elsewhere in the world. Americans have bragging rights about coffee, but should be embarrassed about their inability to understand that human subjects research done elsewhere often applies to Americans and not just "them feriners".

 

[Vocalek]

Posted 8 hours ago

Carl Phillips

Right now, Hans Gilljam from Karolinska is presenting a plenary lecture on the Swedish tobacco experience. It is supposed to be epidemiology themed, but so far he has only given a history (interesting) and talked about meaningless toxicology.

Oh, there is some actually epi. Sadly, it is just wrong: claims that it causes pancreatic cancer, even thought that claim has been debunked by most everyone. And now he is listing every junk science claim ever made by Karolinska people, ignoring the evidence as a whole -- typical "public health" methodology: anything anyone has ever claimed is true.

Interesting observation: A new study that recently came to light found that smoking rates in 1955 were as high as anywhere in Europe, which had not been the (data-free) conventional wisdom.

When observing that male smoking rates are now low compared to women, he manages to avoid saying it is caused by snus (just saying it is "made up for by snus") and claims that thus they are even more addicted. So far he has talked for over 20 minutes about snus and smoking without every hinting that there is a health difference. It must take some serious practice to be able to be talk around the elephant so effectively. At least he acknowledged that there is no gateway effect.

In counting up the number of "smokers", he includes "passive smokers" in the total. Funny that lung cancer among men is so low (as he showed next) given so much "smoking".

This was followed by an extensive review of the evidence that snus has facilitated smoking cessation and replaced smoking as the uptake product, without any support from medics or government. Sadly, he then switches to first-person and talks about how "we" (medics) lobbied for anti-tobacco (not anti-smoking) policy and succeeded. He then goes on to claim that Swedes are healthier, but since that is historically true he implies it is not because of not smoking. But, finally, in the last slide he acknowledges snus has been beneficial and is less harmful than smoking (but "how much less is unknown" - he apparently does not really read the epidemiology he supposedly is expert on). He almost finishes with a pro-THR note, but tries hard to make sure he is not really saying that. Very sad.

 

[Vocalek]

Posted 4 hours ago:

Carl Phillips

The only really annoying time conflict of the conference: I would have really enjoyed the session on plain packaging, watching the participants twist the data to interpret incredibly weak tangential evidence as showing that it matters. But I figured I should go to this (not very well attended) session on "secondary reinforcers" -- i.e., it is not just the nicotine. Or, to paraphrase the introduction remarks, mmmm, cigarettes are yummy.

Jed E. Rose: Recounts his research in separating nicotine delivery from the smoking -- something I have always wanted to do with snus and de-nic cigs (he gave IV nicotine). Simple summary: nicotine without smoke satisfies smokers some, but not as much as de-nic cigs. Further evidence supports importance of lung nicotine receptions. Conclusion (his): THR calls for inhalation product and (big surprise) a pitch for the nicotine pyruvate inhaler (reaches lungs much better than atomizer vapor) that he invented and got very rich selling to Altria. dukesmoking.com for more information

What is really missing from this (my assessment) is willingness to learn: Smokers who want to quit can learn to be satisfied with something that does not perfectly mimic smoking, but the latter will be much more satisfying on day 1, obviously. And, at the risk of sounding like someone other than me, there might be something to be said for making THR nicotine delivery a little bit less intensely reinforcing (others would say "addicting").

Carl Phillips

I decided the other talks in the reinforcers session, about SNPs and rats, were pretty tedious and relatively uninformative, so popped over to see the panel discussion in the plain packaging follies. I missed the short talks, but learned that all five came to the same conclusion (shocking!): calls attention to warning label (undoubtedly true -- the first time someone sees the package), takes away attractiveness of packaging (um, yeah, but does it matter) and market segmenting, and the implications of the packaging that some products are lower risk (never can understand that one).

Great comment from the floor: What is the point, time after time, of proving that people like things that are prettier a bit better than things that are not. More interesting is to know what happens when people in the real world put their plain (or photographically uglified) packs into the new personalizing pack sleeves that have become quite popular in Germany. Other than that, it is just a big cheering section for implementing the plain packaging policies in here, and discussion of how to persuade policy makers. This is a real pity: The Euro SRNT is intent on trying to be a scientific organization, unlike the US SRNT, but this is tending to defeat that goal.

Carl Phillips

Oh, I hit "post" too soon. The discussion turned to the "misinformation from the tobacco companies" (which is what this ilk calls information by tobacco companies) that plain packs will make counterfeiting more attractive. They are trying to claim that there is research that shows this is not so. How do they know this, given that there is no experience with the situation? They did focus groups!

 

[Vocalek]

Posted 3 hours ago:

Carl Phillips

Fagerstrom talking about "is it just nicotine" should have been in previous session: Nicotine-seeking behavior is fairly limited. MAO inhibitors in tobacco may be explanation. There are obviously behavioral, social, sensory components. Snus use is very solitary, narrower experience, does not include a pacifier. Announces renaming FTND as "Fagerstrom Test for Cigarette Dependence", and calls for new tests for smokeless, waterpipes, etc. Not much new here, other than the rename -- kind of an odd thing, since usually updates like that are done by someone else.

NOTE: Karl Fagerstrom invented the Fagerstrom Test for Nicotine Dependence (referred to as FTND in research articles on smoking cessation) way back in 1978. If you want to give it a try, here is an online scored version: Assess Your Risk - Fagerstrom Test for Nicotine Dependence

 

[Spazmelda]

Fascinating! Thanks for reposting it all here.

 

[Vocalek]

Posted 13 hours ago:

Carl Phillips

I have a few more random observations to offer about conversations and talks.

Talking to Murray Laugesen and some other from NZ, I am quite intrigued by the way things are headed there. It sounds like the government is actually tending a bit toward looking for the opportunity to do that right thing re THR. I recall commenting in our forthcoming chapter (in the Marlatt memorial HR book) that New Zealand and Australia have the advantage of having smaller and thus potentially more responsive governments, and thus THR policies could happen quickly. I felt this was a bit too optimistic perhaps, certainly for Australia, but it looks like it might be working out that way.

One thing Murray emphasized to me a couple of different times, though, was that NZ needs to have an effective consumer group -- or any consumer group at all. Even if it is not CASAA-sized, something like what is brewing in Australia would be good. (He also suggested to me that not nearly enough is happening in the UK in this vein and that I should move there. Don't worry -- not going to happen.)

So, if anyone has any connections or anything going on in NZ, please let me know. I would love to get hooked into what might become a success story.