By Derek Yach
IN THE 1970s, a group of students in SA were planning a campaign against tobacco. I was one of them. We paid a visit to Rembrandt, the countrys leading cigarette manufacturer, to hear its side of the story.
Staff showed us shiny floors, introduced us to well-paid employees of all races a rarity in apartheid SA and proudly described the firms extensive support for the arts, culture and the environment.
We replied that this was great, but it failed to address the core issue: their products killed half their regular users and harmed many more. So the campaign went ahead.
For me, it was the start of decades of battle with tobacco companies that led to strong regulations in SA and culminated in the World Health Organisation (WHO) Framework Convention on Tobacco Control, now in effect in almost 180 countries.
Along the way, I learnt to distrust every move by tobacco companies and felt fully justified when an inquiry, supported by the WHO and the World Bank, declared: “Evidence reveals that tobacco companies have operated for many years with the deliberate purpose of subverting the efforts of WHO to control tobacco use. The attempted subversion has been elaborate, well financed, and usually invisible.”
It is not surprising that most people in public health strongly endorse the view of Dr Neil Schluger, a lung specialist and professor of medicine at Columbia University, that, “If there ever was an industry that does not deserve the benefit of the doubt when it comes to protecting or promoting the publics health, it is the tobacco industry.”
Its deceptions have included the development of low-tar products and a crafty message suggesting that they did less harm. Years after their launch, however, research showed that low-tar cigarettes had exactly the opposite effect.
Now we have electronic cigarettes. Is this the latest ruse, or is it really an innovation we should welcome?
Lets review the appalling statistics. There are about 1.3-billion smokers in the world and roughly 6-million smoking-related deaths every year. In the UK alone, smoking causes 80,000 deaths. That is 18% of all deaths.
Whats more, for every death there are 20 smokers suffering from tobacco-related diseases, resulting in 450,000 hospital admissions each year. Yet no other single cause of death and disease can so easily be prevented.
The WHO framework convention stresses the value of government-led measures: increasing excise taxes, banning all marketing and advertising, and promoting smoke-free workplaces.
Early in its development, we invited tobacco company scientists to provide evidence that their harm-reduction measures were real and not merely marketing ploys. Their responses were unconvincing.
At the same time, the first public evidence emerged that, for decades, tobacco companies had a sophisticated understanding of the role of nicotine. But they had failed to act on this knowledge and separate the harm caused by combusted tobacco from the “pleasure” some people obtain from nicotine.
Lets take a quick look at another tobacco product one that has never caught on in the UK. Snus is smokeless tobacco in a little packet that Swedes tuck against their gum in order to get a nicotine buzz. For many years, the increased use of snus versus regular tobacco has been a major factor in Swedish men having the lowest death rate in the EU.
Indeed, death rates from all causes among European men are about 2.5 times higher than among Swedish men thanks, in part, to snus. Also, as snus use has increased, smoking has decreased. Snus was banned in all EU countries except Sweden (and Norway, which isnt in the EU).
In finland, the ban slowed down the drop in smoking.
In Norway, by contrast, snus consumption by adults rose from 4% in 1985 to 28% in 2012 and overall tobacco use fell 20%.
WHAT drove these changes? Tobacco advertising (including for snus) has long been banned in all three countries. Public health authorities speak out against all forms of tobacco, including snus. Nonetheless, consumers, influenced by price and information from social networks, have increased their use of snus.
So what has this to do with the emerging debate over e-cigarettes?
We have seen that snus is banned in most of Europe despite overwhelming evidence that it reduces harm. And now e-cigs and other innovative ways of delivering nicotine without the dangers created by burning tobacco face the same challenge.
Traditionalists demand more of the same policies that have significantly reduced tobacco use: excise taxes, full implementation of smoke-free workplaces and more effective antismoking advertising.
Long-term projections say this would reduce smoking in the US from the current 20% to 10% by 2030. That is welcome but it still leaves millions of smokers at risk.
The call for higher excise taxes ignores rising concern about their regressive effect on poorer and more addicted smokers. It also ignores advances in the genetics of nicotine use, suggesting half of all smokers may not respond to tax increases because of their need for nicotine.
In other words, our one-size-fits-all approach to tobacco control is doomed to fail.
Action on Smoking and Health estimates 2.1-million British adults use e-cigs. About one-third are former smokers, and two-thirds are still smokers. Meanwhile, regular use of e-cigarettes by children and adolescents is confined almost entirely to current and former smokers.
Users claim that e-cigs help them stop smoking entirely (38%) or reduce the amount they smoke (25%).
Robert West, professor of health psychology at University College London, reports e-cig use by never-smokers is negligible and similar to that of nicotine replacement therapy.
In recent years, the rising popularity of e-cigs has more than offset a decrease in use of nicotine replacement therapy. Successful attempts to quit smoking, although escalating, are still low, at 5%-7%.
E-CIGS could play a major role in helping those smokers most addicted to nicotine, who are shifting in increasing numbers from nicotine replacement products to “vaping” as their means of quitting the tobacco habit.
Safety concerns were addressed recently. Two analyses reviewed toxicological, laboratory and clinical research on the potential risks. They concluded e-cigs are far less harmful than smoking, and “significant health benefits are expected in smokers who switch from tobacco to e-cigs”.
Yet governments and the WHO remain unconvinced about the benefits of e-cigs. There is deep distrust of tobacco companies.
This is borne out by article 5.3 of the framework convention, which requires that, “in setting and implementing their public health policies with respect to tobacco control, parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law” that is, avoid interaction with tobacco firms. But this policy is impossible to implement in countries where democratic law-making processes require interaction with all stakeholders, or where the government owns a tobacco company.
Moreover, it limits the potential to use scientific discoveries made by tobacco companies. At a WHO tobacco control conference last October, governments stressed the need to protect tobacco control activities from all commercial and other interests. That effectively means not talking to researchers developing new and safer products.
They also wanted governments to consider prohibiting or regulating e-cigs as tobacco products which would be a huge boost to the deadly status quo.
The US Food and Drug Administration (FDA) has already announced its intention to regulate e-cigs as tobacco products. About $2.2bn was spent on e-cigs in America last year, exceeding the amount spent on nicotine replacement therapy but still representing a small part of the $85bn cigarette market.
At the same time, however, the FDA seems to favour a transition away from lethal combustible products. Mitch Zeller, director of its Centre for Tobacco Products, wants us to look at nicotine differently. People “smoke for nicotine but die from tar”, he says, and new products represent a public health opportunity.
The FDAs measured approach is in contrast to the continued unscientific approach of the US Centres for Disease Control and Prevention, whose director, Dr Tom Frieden, stated last year that “many kids are starting out with e-cigarettes and going on to smoke conventional cigarettes”. They have yet to produce evidence of this.
IN NOVEMBER, Penny Woods from the British Lung Foundation said “(new) data should again alleviate the fears expressed by some over an e-cig gateway effect”.
Let us spell this out. Unsupported statements are accepted as truth by policy makers and used as the basis for stringent regulation of e-cigarettes in many jurisdictions. This may cause more harm than good.
The benefits of e-cigs in helping smokers quit or cut down should be weighed against the danger of either recruiting new smokers or creating e-cig addicts. So far, there is no evidence that either of these things is happening.
Studies in both Britain and America suggest that, as e-cig use increases, youth cigarette consumption declines.
Why are we in this position? One reason is that governments have become addicted to tobacco excise tax and may fear that, as e-cigs take off, they will lose a valuable source of revenue.
Many leading academics and nongovernmental organisations exert strong influence at the WHO, within governments, in the media and among the general public. In the past they helped bring tobacco control out of the shadows and into the health policy mainstream. Now, alas, their intransigence threatens more profound progress.
We need clear messages to smokers about the safety and benefits of e-cigs. An example is the statement made in March last year on the Royal College of Physicians website that “the main benefit of e-cigarettes is that they provide inhalable nicotine in a formulation that mimics the behavioural components of smoking but has relatively little risk .
“Switching completely from tobacco to e-cigarettes achieves much the same in health terms as does quitting smoking and all nicotine use completely.
“Furthermore risks associated with passive exposure to e-cigarette vapour are far less than those associated with passive exposure to tobacco smoke.”
If influential health officials were to make these points repeatedly, public sentiment towards e-cigarettes would shift quickly. And this could be done at the same time as strengthening antismoking measures.
WE SHOULD praise “good” e-cig companies that commit to safety, to avoiding youth marketing and to making smoking obsolete.
They need to be explicit about their long-term plans. Are they seriously committed to harm reduction, or are they introducing new products simply to delay progress and confuse policy makers, as many believe?
From my meetings with major tobacco companies, it is clear that they are hedging their bets.
Some of them have indicated, in private, a long-term goal of moving out of manufacturing harmful tobacco products but these statements are not enough to inspire trust. Tobacco companies intention to change must be stated publicly and backed by action.
Other market sectors need to adapt to the reality of e-cigs as a force for good. Retailers should voluntarily withdraw cigarettes from stores, or at least reduce their prominence, in favour of e-cigs and nicotine replacement therapies.
CVS Health has yet to offer e-cigs, despite the fact that they work better than pharmaceutical products. Life insurers still treat e-cig users as regular smokers when they calculate premiums.
This is shortsighted and misses a golden opportunity to spell out the benefits of quitting smoking and the positive effect of switching to e-cigs on peoples longevity.
At the moment, its estimated there will be a billion tobacco-related deaths before 2100. That is a dreadful prospect. E-cigs and other nicotine-delivery devices such as vaping pipes offer us the chance to reduce that total.
All of us involved in tobacco control need to keep that prize in mind as we redouble efforts to make up for 50 years of ignoring the simple truth that smoking kills and nicotine does not.
Yach is executive director of the Vitality Institute and has headed tobacco control at the WHO. This article is from Spectator Health.
Image Caption: Damien Hoops uses an electronic cigarette at The Vapor Spot bar in Los Angeles in March last year. Pictures: REUTERS/MARIO ANZUONI (via BDLive)
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