But while the main thrust of Ethan’s oration was to compare drug and tobacco harm reduction (THR) challenges, he did touch on some of the most important themes of the conference, so I will use parts of his oration to reflect on the conference as a whole.
He talked about language – and for me one of the most consistent themes running through the whole event was communications in all its forms including use of language and messaging. There is much talk of how vaping has disrupted both the tobacco industry and the narrative as to how we solve the smoking problem. But we need to disrupt the language too, in particular, the notion of addiction as it relates to nicotine. Yes, you can look at all the clinical definitions of addiction and see that nicotine appears to tick the boxes of an addictive substance. But as Ethan defines it, an addiction is dependency plus a problem. And I agree. From any scientific, clinical or social perspective, the idea that nicotine ‘addiction’ can be equated with addiction to heroin, cocaine, methamphetamine or alcohol is patently ridiculous. But the notion of addiction as a shameful, degrading character flaw is deeply embedded in society: in a western liberal capitalist context, it undermines the Holy Grail of freedom or more specifically, the consumerist freedom to choose.
Delegates said to me they thought the quality of the poster presentations had significantly improved from last year and sitting through the opening ISoNTech [check UC and LC on this – always defeats me} session, the science on display was impressive. But in this respect, I write as a lay person and we do need to find a way of condensing the science into a puree that is more easily digestible by the media and therefore the general public. Who can blame people for being confused when an anti-vaping study is published one week followed next week by one which disputes vaping’s bad reputation. But if you did a global media analysis, anti-vaping studies would dominate not least because the media love a bad news story and interviewing a Professor who wants to ban something is always good copy.
Addressing smoking history, Amelia Howard from Canada referred to what anti-smoking campaigners called the Big Tobacco playbook which “refers to the PR machine that the tobacco companies deployed in various ways to shape public perception of the risks of smoking and cast doubt on scientific consensus”. Strike out the words Big Tobacco and replace with Tobacco Control Lobby?
I have no problem with the drive to cut smoking rates and recent results from Sweden, the UK and the USA are very encouraging on that score. But what is pretty despicable is that element within the public health community playing fast and loose with the lives of those who cannot or don’t want to quit. And this in my view is nothing to do with ‘unintended consequences’ of tobacco control policy. Those wedded to quit or die while legislating vaping out of existence know exactly what they are doing.
I was much taken with the quote from Martin Dockrell of Public Health England interviewed during the conference when he said that to persist in telling the general public that vaping is as, if not more, dangerous than smoking cigarettes is “the lie that kills”. Campaign slogan anybody?
Ethan entreated us not to ditch the term harm reduction: this issue has often come up in drug reform circles as anti-reformers dismiss harm reduction as a stalking horse for legalisation. The THR world doesn’t have that problem, although in response to Ethan’s claim that the THR is on ‘easy street’ compared to drug reform, I would point out that I doubt drug harm reduction evidence has been rubbished on the grounds that proponents must be in the pocket of Big Heroin or Big Cocaine. As a term, harm reduction is well-embedded in drug policy discourse: organisations and journals have adopted it. But as John Boley who has worked in various Far East countries reminded us, the language we are used to in the west doesn’t play in all countries. He made a plea for more helpful language; for harm reduction read safer product; for less harmful read safer; phonetically speaking, vape in Thai can mean a motorcycle or a microwave And when Singapore talks of regulation, they mean prohibition.
Ethan made another telling point that public health is not synonymous with harm reduction. For him, harm reduction resides at the intersection between public health on the one hand and human rights and civil liberties on the other. And this comes back to my earlier point about freedom. Simply put, public health is about preventing health harms for the benefit of the majority, the greatest good for the greatest number. And that doesn’t always chime with the best interests of individual civil liberties, for example, people quarantined in their homes because of the outbreak of disease like Ebola.
But the quasi-religious, moralistic tenor of tobacco lobby rhetoric flying under the flag of public health means that public health in the wrong hands is dangerous. And ‘quasi-religious’ is entirely appropriate terminology: We heard from the platform and speaking to another delegate over a beer, examples of public health officials who entirely agree with THR but dare not speak out for fear of losing their jobs. Thus adhering to THR principles can quite literally be regarded as heresy and in the true spirit of the Inquisition, your career goes up in flames.
Potentially more iniquitous is the crusade to make the world ‘drug free’ or ‘tobacco free’ which in reality is a war against people because you can’t do battle with an inanimate object. Ethan declared very firmly that THR advocates should not get drawn into the anti-smoking crusade however much distance needs to be put between advocacy and industry. Why? Because those most affected by such a crusade are the poorest and most marginalised and vulnerable people – the people most despised and feared. Those with the least freedom to choose in society. We heard powerful presentations from Helen Redmond and Kevin McGirr on the very high levels of smoking among those with a psychiatric diagnosis, because cigarettes deliver much more than just the nicotine. But in the process, this group have their lives cut short by anything up to 25 years demonstrating that ready and cheap access to ENDS for this group is critical.
We heard presentations from around the world, but I was intrigued by the situation in India which underlines how the public health implications of alternative nicotine products can be both global and very country specific. Rajesh Sharan presented some startling figures; after China, India has more smokers than anywhere else in the world – 12% of all smokers live in India - and is second only to China in tobacco production, some 800 million kilos per annum. There are three main smoking groups – young urban cigarette smokers, more rural forms of smoking (water pipes etc) and the largest groups of all – at least 440 million people – who chew tobacco. With that level of commercial investment in the industry, not surprising that little control on smoking is exerted by the government. Yet some Indian states have already banned ENDS, even though the new products may never make much inroad into the market for the very reason that most people chew tobacco. The last Framework Convention on Tobacco Control meeting (with India and China round the table) was held in Delhi and apparently the meeting pulled back from the brink of trying to ban ENDS altogether.
But figures that Professor Sharan did not present, but which came out in a conference interview with him were that among the nearly 10 million people who die every year in India from smoking-related disease, the most prevalent form of cancer is oral and upper tract – most associated with chewing tobacco. So why has snus not taken off in India? Powerful vested interests in the industry must be a factor. But during his presentation, Professor Sharan pointed out the difficulty of getting harm reduction messages across to a largely rural population speaking 250 languages and with deeply entrenched smoking cultures. But tellingly, in the interview, he specifically mentioned the snus ban in Europe as setting the example being followed by India. Maybe a genuine example of an unintended consequence of tobacco control policy.
There was lots of optimistic talk in and around the conference that we are on the cusp of a public health revolution that could save millions of lives. Inevitably the most positive views came from tobacco industry representatives and industry consultants, although some did caution that regulation could freeze out innovation and kill the emerging industry. And I think this is a real threat. It feels to me that, despite falling rates of smoking in some countries, the idea that smoking can be legislated out of existence is a chimera. Instead the tobacco control lobby is taking it out on a fledgling business trying to stifle it in the nest.
Some speakers likened the revolution in reduced risk nicotine products to the rapid and spectacular growth of Big Tech – Apple, Google, Amazon and Facebook – coming out of nowhere from garages and back bedrooms to change the world. But from a legislative point of view there is a big difference. When it comes to dealing with the transnational issues arising from the ubiquitous nature of our online lives – cybercrime, pornography, privacy, intellectual property, social media and terrorism and the Dark Net, lawmakers are hardly out the starting blocks. Not so tobacco regulators: there is generally sufficient anti-tobacco legislation in place which can be simply extended to cover new technologies.
However, there may be an even more disruptive future for the tobacco industry. Over the course of three days, there were many fine presentations, But the moment I really sat up in my seat was provided by Dr Michael Hufford from Pinney Associates when he revealed that a tobacco-owned biotech company can turn tobacco leaf into a personalised vaccine for non-Hodgkins Lymphoma and another vaccine product used to combat Ebola. Imagine the hand-wringing at WHO if Big Tobacco became a Big Pharma player.
So what to do? THR advocates have to find ways of changing the narrative, of being able as Ethan put it to ‘raise the right eyebrows’. He mentioned the emotional impact of putting ‘nice ordinary people’ in front of Congressional meetings to tell politicians how the medicinal use of cannabis has dramatically improved their lives. And THR has these examples: Judy Gibson told how she just came across Vera aged 73 and how delighted her family was that she had switched to vaping. I overheard Terry Walker, now 85 years old, tell Hon Lik that he gave up smoking at 69 with only 55% lung function – now with e-cigarettes, that has risen to 88%. These are good news stories are out there and they will resonate with politicians and the wider population.
Financing advocacy is a big issue: Atakan Befrits from Sweden said he has no financial interests to declare because he has no finances and this will resonate with advocacy groups everywhere. But it goes without saying that any funding has to be independent of any industry connections and so approaches to major international grant making bodies like Open Society need to be considered.
And then there are the possibilities of legal challenges. We heard about the UK advocacy challenge to the EU snus ban to be considered by the European Court of Justice and a challenge by the US vaping industry to the FDA deeming regulations. But I was also struck by the presentation of Marina Foltea on the potential challenge to ENDS bans as a breach of World Trade Organisation product discrimination regulations and Jeannie Cameron’s observation that harm reduction is actually written into the FCTC from a time back in 2000 before e-cigarettes were even thought of. Could there be any kind of legal challenge here?
The closing session introduced us to Olivier Theraulaz of the Swiss vaping association who bravely declared his former heroin use. He said how, having been completely let done by the treatment system, he was literally saved by a sympathetic doctor who took a completely non-judgemental view of his situation – a lesson to any smoking cessation professionals who resolutely refuse to endorse ENDS for clients who struggle to give up. And to end it all, a smoking cessation health professional and ENDS champion, Louise Ross who made a plea for collaborative working or as she put it, ‘let’s not piss on each other’s chips”. Follow that – by coming to Warsaw next year.