Harry Sharpio | 13 July 2016
Having spent over 35 years working in the field of illegal drugs, this was my first foray into the world of tobacco or more specifically the current worldwide controversy over e-cigarettes. What I learnt from my two days at the conference was both fascinating and appalling.
Until 2014, those advocating for tobacco harm reduction had no international forum for the exchange of information and ideas. Enter Professor Gerry Stimson, a UK social science drugs researcher who conducted the pioneering UK research into the benefit of harm reduction interventions to reduce the impact of HIV/AIDS among injecting drug users and established the International Harm Reduction Association. Seeing similar issues arising from the world of tobacco, he, along with Paddy Costall who organised the IHRA conferences, set up the GFN to allow for all interests to meet, so much so that this years' conference was literally standing room only. With delegates from 55 countries, they reflected the breadth of engagement in this smoking (or should I say vaping) hot topic: clinical and academic researchers, doctors, policy analysts, vaping manufacturers and consumer advocates. And there in the room too was Big Tobacco, probably unheard of in the world of tobacco control (unless of course you are the Chinese delegation at the WHO FCTC COP meetings). Having spent years going to drug conferences, it was almost like exchanging views over coffee with somebody from a south American drug cartel.
The conference was prefaced by the European premiere showing of A Billion Lives directed by Aaron Biebert. The title takes its cue from the calculation by the World Health Organisation of the estimated death toll this century from smoking cigarettes. The first section rehearses the dark history of Big Tobacco including an illuminating interview with David Goerlitz who was literally the face of Winston cigarettes in the 1980s, before laying out exactly what the vaping community and those clinicians and in public health are up against in making the case for e-cigarettes. The film makes clear that major national and international medical organisations and regulatory bodies have taken against alternative nicotine delivery systems, probably through a continued deep suspicion of Big Tobacco who have been slowly investing in the new technologies over the past decade and what feels like a moral rather than clinical antipathy towards the continued use of nicotine.
The film encapsulated for me those fascinating and appalling aspects of this issue. The fascination comes from the fact that after decades of clear divisions between tobacco companies and the health community, disruptive technology has not only introduced an entirely new delivery system for nicotine, but also caused a seismic crack in the fault lines between commerce and health. And appalling because of the lengths that national and international regulators, medical bodies and NGOs are going in order to seriously undermine what is a clear public health benefit on a global scale. And what's more, it is no secret, as the film shows, that much of what passes for research and misleading public health messages are being funded by Big Pharma – who are also lobbying regulators - to protect their own NRT profits.
In fact from the perspective of the delegates, only the UK has so far emerged with any credit among nations involved in the global debate. Public Health England published a report which declared that the product was “95% safer than cigarettes” while the Royal College of Physicians concluded that “On the basis of available evidence, the RCP believes that e-cigarettes could lead to significant falls in the prevalence of smoking in the UK, prevent many deaths and episodes of serious illness, and help to reduce the social inequalities in health that tobacco smoking currently exacerbates”. Judith Wolters from Australia's New Nicotine Alliance declared that the vaping community looked to the UK as a beacon of sanity and reason in what has become a hard line approach from the wide range of tobacco control interests.
If there was one over-riding emotion in the room it was passion: the vaping community feels under siege from the hostile forces around them and as ex-smokers, they are understandably outraged at attempts to prevent them from actually leading more healthy lives.
That passion is no less apparent among clinicians who are similarly outraged that peer-reviewed academic journals are publishing what Clive Bates from Counterfactual calls “junk science”. In a one-to-one interview with Greek cardiologist Dr Konstantinos Farsalinos, he explained to me one of the more notorious examples which appeared in the New England Journal of Medicine in January 2015.Propylene glycol and glycerol are used in nicotine liquids to bulk out the flavours and create the vapour. One chemical created by the heating of propylene glycerol is formaldehyde which at sufficient levels is possibly carcinogenic. In order to show that e-cigarettes emit high levels of formaldehyde, the researchers ignited an e-cigarette to a temperature that no vaper could possibly tolerate. For Dr Faraslinos “it is like roasting a piece of meat until it was absolutely black and inedible and then complaining about the nature of meat. But low levels of formaldehyde are in the air we breathe, the amount you inhale from an e-cigarette is no more than you would sitting at home watching the TV”. Apparently though, neither the authors nor the journal would admit any mistakes and refused to retract the paper. Dr Farsalinos said he spends too much time trying to replicate studies that should have never been published in the first place.
The other area of bad science causing anger among presenters was that trying to establish that vaping is a gateway to smoking among young people or will renormalise smoking among ex-smokers. Professor Linda Bauld, from Stirling University highlighted two particularly flawed studies which received much media publicity. One from Scotland purporting to show that young people are more likely to try e-cigarettes simply by seeing point of sale displays while the other study, the much criticised study by Kalkhoran and Glantz claimed that e-cigarettes don't help smokers quit. But as Professor Neil McKeganey pointed out, it isn't just this there is flawed research out there, but such results are a “catastrophic proposition, the consequences of which are very tight legislation” which will not threatens to offset all the benefits of e-cigarettes, but in the words of vaping activist David Dorn “will kill people” as they take the easy option and carry on smoking instead of being encouraged to switch.
And regarding control, the most concerning to the conference delegates are the European Tobacco Products Directive (TPD) and the Federal Drug Administration (FDA) Deeming Regulations both of which have been enacted this year. The story of snus highlights the issues.
According to the WHO data, the use of snus has resulted in fewer tobacco-related deaths among Swedish men than anywhere else in Europe. But snus has been banned in all European countries except Sweden as long ago as 1992. Yet despite the growing evidence in favour of smokeless tobacco products and some legal challenges by the manufacturer Swedish Match, the ban remains under the new European TPD. Snus was not banned in the USA, but according to the Swedish Match representative at the GFN Conference, when the company wanted to introduce a modified risk product, they had to submit an evidence report to the FDA which eventually ran to 140,000 pages. The irony of such restrictive legislation and unreasonable level of evidential support mean that only Big Tobacco has the resources to comply, driving out smaller, independent companies which limits competition and innovation.
Aside from despair over draconian legislation and disgust at the refusal to accept the evidence for e-cigarettes while peddling bad science, other important themes emerged.
Perhaps the real nub of the whole vaping controversy is the pleasure principle, something which seems to elude the whole anti-e-cigarette community, probably because many of them have never been smokers. As David Dorn said, “It's why e-cigarettes work as well they do...something which smokers can enjoy which at the end of the day won’t kill them”. Research undertaken by Dr Chris Russell at Glasgow University underlines the point; he talks of the taste, the nicotine hit and the social community that surrounds vaping, “by all accounts, other ways of quitting are just miserable. Now these people have come across something that not only makes quitting possible, but enjoyable. Who would have thought there would be products like that ten years ago”.
Across many parts of the developed world, smoking rates have been falling. But when you look deeper into the figures, you find that rates are still high among those most socially disadvantaged and among sub-populations with complex needs including those in poor mental health and/or with substance misuse problems. Professor Marewa Glover from New Zealand gave an impassioned Michael Russell Memorial Lecture on the plight of Maori women in this respect while on a more positive note, Louise Ross who runs Leicester City smoking cession services spoke of a pioneering project where she has convinced local health officials to allow vaping on mental health wards, especially for the elderly and frail, “why should they be made to go outside?” she asks.
Looking at this issue upstream, there could be some important global political consequences should tobacco control officials continue to block the growth of alternative nicotine delivery systems particularly in the developing world where smoking rates are still very high. After all, United Nation Universal Declaration of Human Rights is supposed to trump all other international treaties. Could the WHO be brought to book by denying the right to good health for millions of the world's citizens?
Which leads finally to the cross-over from drugs harm reduction where the right to health - particularly for injecting drug users - is an ongoing global struggle. Dr Chris Ford is the Clinical Director of the International Doctors for Healthy Drug Policies and urged the vaping community to make their voices heard in much the same way as drug user activists across the world have done as their campaigning agendas precisely map onto each other. She might also have added that smoking rates among drug service users in the UK are at least three times the national average and that those in the older user age groups are dying in increasing numbers as drug use, smoking and drinking co-morbidities begin to impact on the ageing body.
There were significant legislative developments between the Second and Third GFN conferences. What can we expect when the conference reconvenes next year in Warsaw? What for example, will be the impact on the TPD of the UK decision to leave the EU? Will there be successful legal challenges to the FDA Deeming Regulations? What can be done to win the hearts and minds of the public in the face of continued publicity given to the 'bad news' about vaping? Come back next year and find out.