Researchers analysed data from 1,736 adults: about 85% said nicotine is what causes people to want to keep smoking, while 53% said they believed nicotine causes most of the cancer related to smoking. While smokers were three times more likely that e-cigarette users to believe nicotine caused cancer, even so nearly 15% of e-cig users also believed this. Only 31.6% of smokers agreed that e-cigs are less harmful than cigarettes. This mirrors research conducted by UK ASH in 2015 which found that increasing numbers of people believed that e-cigarettes are at least as harmful as cigarettes.
The blame for apparently succeeding in convincing the media, the general population and smokers, lies fairly and squarely with national governments, medical and campaigning groups and their international counterparts especially the WHO. This is a shocking state of affairs and must surely contravene every moral and ethical tenet of medical practice and public health.
In concert with progress in medical science, public health has enjoyed a laudable history in tackling the scourge of global communicable diseases like malaria, TB, cholera, smallpox and a host of others through, among a variety of interventions, vaccination and sanitation programmes. Trying to develop effective programmes to address non-communicable diseases, however, has proved more problematic and even more so when simply trying to encourage people to behave better for the benefit their own safety and the safety of others. Either way, these exhortations, backed by evidence, are delivered mainly through public health campaigns.
Some public health campaigns are surely uncontroversial like those backed by legislation to address drink-driving and to demonstrate the need to wear a seat belt. There should also be much more effort into warning of the dangers of using a cell/mobile phone while driving. There is weak UK law on this, but national public messaging has been non-existent. Maybe it’s all the fault of Big Phone. But life isn’t always that straightforward; in the UK we are encouraged to eat at least five portions of fruit and veg a day. Why five, why not six or eight? I doubt there is much hard data around this, simply that governments can’t just say, ‘Eat more fruit and veg’ because back comes the answer, ‘OK. How much more?’ In Canada for adult males, the recommended intake is ten portions a day. Are Canadian men in need of double the dose?
In the UK if a batch of bad (which often means strong) drugs are found in a locality, the police will issue a warning and the public health authorities will alert local health professionals. But it is unclear what recipients are meant to do with this information and some would argue that alerting drug users to the existence of the ‘good stuff’ down the street is not without its hazards. Another flag that waves in the breeze is alcohol during pregnancy. Health ‘experts’ change their mind on whether or not a glass of Beaujolais is OK as often as those anywhere near the nerve agent attack in Salisbury are being urged to wash their socks by the Chief Medical Officer.
But essentially, no harm done: conflicting advice is inevitable when the science is inconclusive or evolving and governments understandably feel they should do what they can in the interests of duty of care. Telling lies and spreading misinformation that has a clear potential to do actual harm is another matter entirely. There is no justification for peddling false health information in the interests of moral, ideological or political expediency.
In response to US government propaganda asserting that cigarettes and smokeless tobacco were equally dangerous, Lynn Kozlowski and Richard O’Connor wrote a paper in 2003 calling for a public health code of ethics similar to that which governed the use of human subjects in clinical research.
They took their cue from the Belmont Report, published in 1978 by the National Commission for the Protection of Human Subjects in Biomedical and Behavioral Research. One of its three core principles was respect for the individual - showing a lack of respect for an individual included withholding information that prevented the person making an informed judgement. This argued Kozlowski and O’Connor, was precisely what was happening when, whatever the motivation, smokers were not being informed that there were demonstrably safer ways of consuming nicotine. And it wasn’t just in human research that the importance of honesty in public health was emphasised. The authors quoted the American Public Health Association and the Society of Public Health Education who both asserted that individual self-determination and freedom of choice must underpin public health interventions.
Since the article was written, the disruptive technology of e-cigarettes had propelled the issue of tobacco harm reduction and integrity-driven public health messaging onto the global stage. It is here that the WHO have a particular obligation to show public health leadership. Most low and middle income countries, where most of the world’s smokers live and die, have little in the way of resources to undertake their own health research and rely on WHO guidance in formulating their own public health policies So it is less than helpful when Dr Kachornsak Kaewchamras, Deputy Director-General of Thailand’s Department of Disease Control, cited the WHO in warning that e-cigarettes are no help in quitting, are addictive and pose health risks including lung and esophageal cancer.