Sometime in the 1990s, the UK TV station Channel 4 conducted what was called A Citizens’ Jury concerning drugs. A group of 12 citizens were chosen to hear some actual evidence-based information about drugs They were quizzed before the show about their knowledge and attitude to drugs with predictable results. Then over a period of days they heard testimony about drug harm reduction, the arguments for reform and drug effects. At the time the American government and UK anti-drug campaigners were spouting ‘fake news’ and bogus statistics about Holland being dragged down into a drug morass for allowing cannabis to be smoked in designated cafes. The jury were taken to Holland so they could see for themselves that it was all nonsense. At the end of the process, they were asked again about their previously held views which overall had changed from being black/white to much more nuanced and considered. The south London borough of Lambeth – an area with serious drug problems – conducted a similar exercise with similar results. I suspect the idea of putting key policy issues in front of ordinary people like this was quite innovative back in the 1990s, but now if you google ‘Citizens’ Juries’, there are many policy papers and discussions about their value.
So what’s the point of this? I think it speaks to the importance of not simply challenging entrenched views via social media, opinion pieces or academic papers, but as far as possible to get in front of people to address their views or concerns – and in this case, I am obviously talking about tobacco harm reduction as it applies to safer nicotine products (SNP). The parliamentary enquiry is another important avenue for evidence to be properly scrutinised by non-experts who are the elected representatives of the people. Even though the governments of the UK and Australia take a very different view of SNP, parliamentarians in both countries to a greater or lesser extent reacted favourably to SNP, even to the extent that the Australian chair of their enquiry wrote a counter-view to his own committee’s report.
Now, I’m not so naïve to imagine that the opposition to SNP is entirely based on health grounds; the recent decision of the European Court of Justice upholding of the snus ban is proof enough, but I do believe that nothing beats face-to-face discussion – ask anybody trying to do business in China – they need to see your face, your body language. Politicians, policy makers and officials especially need to hear the counter-arguments outside of the WHO/Bloomberg bubble.
I know that activists, academics and clinicians around the world take every opportunity to make the case for tobacco harm reduction, whether through conference presentations (assuming they are allowed to attend by the Thought Police of Tobacco Control) and meetings with influential officials. This does allow for the hard questions to be asked. And they need to be asked.
In a country planning to ban or strictly control SNP or to try and bend them into medicinal products, what do officials think will happen? What do they think will be the outcome for smokers looking to switch if flavours are banned, if genuine concerns about youth health turn into tambourine bashing crusades? How do they think smokers will react to being told they can only access SNP if they are sick with the ‘disease’ of smoking – and that such devices will be sold as ‘smoking cessation’ kits and that they will be denied the choice of using SNP as opportunities for socialisation because of public vaping bans and ultimately asked to accept that using an e-cigarette or a heat not burn device is only valid as the exit ramp from smoking? What do they actually believe will happen? How convinced are they that mainstream tobacco controls will reduce the death toll? What is stopping them from taking a harm reduction approach? The list goes on.
So for example, the Jordanian government has just issued a fatwa against e-cigarettes. The statement said that the prohibition was based on the Quranic verses which prohibit “what is evil” and commands people not to “cast themselves into ruin with their own hands”. And this in a country, as reported by the WHO, where a million people are spending over $800m a year on tobacco, involving 9000 children between 10-14 and killing more than 3,100 Jordanians annually.
Or this from the Kenyan health ministry who define a cigarette as anything that contains nicotine.
Even in a country like New Zealand whose government has taken a welcome and progressive approach to SNP, there is confusion in its latest legislative proposals which leave one slightly dazed. For example, the cabinet paper and policy advice noted there is no harm from second hand vapour. The advice said "Vaping products release negligible levels of nicotine and other toxicants into ambient air with no identified health risks to bystanders”. Yet the policy proposal is to ban vaping in workplaces. The legislation also proposes the same point of sale display and advertising bans as smoked tobacco. You have to ask the question, why treat vaping as harmful as smoking? And ultimately why are political perceptions allowed to cloud the clinical reality.
With his permission, I am reprinting some very insightful comments from Canadian lawyer David Sweanor comparing the Swedish approach to car safety and snus.
“I followed with interest recent comments about Sweden and the rejection by some people of any role of snus in that country having achieved such impressively low rates of cigarette smoking. Sweden is widely recognised as having a ‘safety culture’ and has reduced premature deaths impressively. I think the local and global response to the application of that culture to tobacco products is a fascinating glimpse into the realm of moral psychology.
I also think that comparing views on snus to the reaction to the Swedish experience in dealing with traffic fatalities is very telling.
Sweden has led the world in auto safety, just as it has in tobacco harm reduction. Nils Bohlin’s globally adopted three-point seatbelts, combined with such things as laminated windscreens, rear-facing child seats, side-impact airbags, active head restraint, use of daytime running lights, etc. made Swedish automobiles the standard in safety. In the 1970s Sweden had roughly 1,200 annual deaths from motor vehicle accidents. By the beginning of the 2000s, despite a tripling in traffic, the number had fallen to 600. The pattern of increased vehicle use and decreased deaths has continued and by 2017 annual deaths were down to 253. If we look at this in terms of the death rate per distance driven, Sweden appears to have led the world by decreasing automobile death rates by about 94% since the 1970s.
If someone points out this data, and attributes much of the outstanding success in Sweden to substitution of safer products, heads merely nod. It is very unlikely anyone will claim that safer automobiles had nothing to do with any decline in traffic fatalities. Or try to attribute the decline solely to other factors, like their public education campaigns. Or make accusations about anyone discussing the impact of auto safety somehow being a shill for Big Auto. Even less likely that you will hear of laws that got passed elsewhere to ban Swedish auto safety innovations from reaching other markets, or of courts upholding such bans because ‘all cars are dangerous’. Or see seemingly reputable global bodies combining Swedish automotive products with massively more dangerous ones used elsewhere so as to conclude ‘cars kill’ and thus support efforts to constrain access to, and truthful information about, Swedish technology.
I think Alderman, Dollar and Kozlowski nailed this issue in their 2010 paper on the role of moral psychology in debates on smokeless tobacco. Comparing the reactions to auto risk reduction and tobacco risk reduction we also see the same individuals and institutions taking very different moral psychological positions – an autonomy standard on cars and a purity one on tobacco. With 20,000 daily deaths globally from cigarette smoking I think we also see just how convincingly and tragically moral psychology can trump moral philosophy.
Interesting development here…….
Reuters reports a Bloomberg Philanthropies-backed “small” NGO, Socio Economic and Educational Development Society (SEEDS), “will not be allowed to carry out tobacco-control work in New Delhi after it failed to disclose its funding”, according to S.K. Arora, the city’s chief tobacco control officer, and a memo seen by Reuters. Arora said the action seeks to promote transparency, but an anti-tobacco activist in India, who did not wish to be named, said, “This is sending a wrong message. They are basically deterring tobacco control”. Arora wrote, “These days, the government of India is very particular on international funding and is investigating the actual objectives of various international funding agencies including Bloomberg”. All internationally funded non-profits are “completely prohibited to execute any activity under tobacco control” without approval by the state government, the circular said.
And finally – UK getting something right….
In an op-ed in Forbes (11/19, Forbes) Chairman and Editor-in-Chief of Forbes Media Steve Forbes criticizes the FDA’s moves to regulate menthol and e-cigarettes, arguing that there are “no rational reasons” for “healthcare officials and antismoking crusaders” to wage “war against vaping”. Forbes argues that many of the youth these groups are seeking to protect “would be smoking and/or drinking more if they didn’t vape”. Forbes urges nations to follow Britain’s model, where “lawmakers encourage vaping” and the nation “has the second-lowest smoking rate in Europe”.