I am a big fan of The Guardian; its editorial positioning lines up with my left-liberal views and I have been a regular reader of its articles for many years. Recently it has taken up the cudgels against Big Tobacco, which at one level is strange because in most of the countries where the paper is read, smoking has been in steep decline with the companies on the legal backfoot time and again, for instance, regarding new legislation about plain packaging. More generally, the long and tawdry history of tobacco company deceit is hardly news.
However, fair play, there is still much to be done to track company activities. Sadly, in the process, and no doubt assisted in their efforts by funding from Vital Strategies (itself a grantee of Bloomberg Philanthropies’ mega-anti-tobacco fund), The Guardian has gone fully gung-ho on the trope that tobacco harm reduction as manifested in safer nicotine products is just another Big Tobacco con trick.
The most recent manifestation of this was the comment piece published on 16th February and headlined “We ignored the evidence linking cigarettes to cancer. Let's not do that with vaping”. OK so straight away, even before you start reading, there is a problem. There is no balance of evidence that comes anywhere near linking vaping to cancer.
Then comes the strap line: “E-cigarettes and vaping has increased in teens since 2011, and we still don’t know the long-term health effects”. Of course, teens are going to experiment with a novelty product, but there is no evidence that this leads to regular vaping at a population level, let alone a gateway to regular smoking. And as far as the long-term evidence is concerned, as the epidemiologist and statistician Austin Bradford Hill said in 1965, “All scientific work is incomplete - whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer upon us a freedom to ignore the knowledge we already have”. And the global balance of evidence is that vaping is significantly safer than lighting a cigarette.
The first paragraphs rehearse the whole history of how it took several years for the links between smoking and lung cancer to be accepted. But it is disingenuous to make that a read across to the situation with e-cigarettes. No of course, we don’t know everything there is to know, but the evidence amply demonstrates that what we do know means that e-cigarettes are far safer than cigarettes by a country mile. If the balance of the independent evidence didn’t show this, then the whole issue of e-cigarettes would never have become the controversy it is, splitting the international public health community asunder.
“The high temperature reached by e-cigarette solutions can also generate numerous toxic substances which get inhaled directly into the lungs. These substances cause lung inflammation, another well-known precursor to cancer and other lung diseases. E-cigarette vapor may disable protective immune cells in the lung, cells which are vital to the clearance of harmful particles from the lungs and which may have a role in surveillance against precancerous cells. All of these effects are magnified with the addition of nicotine to the vapor”.
The whole point about e-liquid is that in normal use, it is not heated to high temperatures. Where the misleading junk science kicks in is to deliberately heat the liquid way higher than any vaper would tolerate and then claim all kinds of bad effects. To use one famous analogy; it is like burning toast until it is black and then claiming toast causes cancer.
“Although many teenagers may vape with just “flavoring”, a high proportion of vaping teens are also using e-cigarettes for the nicotine, which should justifiably raise fears that vaping will become a gateway for long-term addiction and potentially for transition to regular cigarette use. Shockingly, a single JUUL cartridge may contain as much nicotine as a whole pack of regular cigarettes”.
Fears might be ‘justified’ but are not borne out by evidence. And ‘shockingly’, a single JUUL cartridge contains about as much nicotine as three not twenty cigarettes. As some smart teens tweeted, if one cartridge of JUUL is the same as a pack of fags why bother with JUUL? And this is the tragedy of this kind of misinformation; those kids who were going to smoke anyway and instead are trying e-cigs are saying ‘I might as well smoke’ which will be a catastrophe for US teen smoking stats which have been plummeting despite e-cigs being around for over a decade.
And finally, more ‘shocks’:
“We remain shockingly ignorant about what the combustible liquids within e-cigarettes actually contain. We already made that mistake with tobacco and cigarettes. Without a doubt turning a blind eye and minimizing the risks of tobacco hurt people – our family members, our friends, and our colleagues – and helped to inflict an enormous cancer burden on them and upon our society. There are few things as heartbreaking as seeing the regret and self-blame of a former smoker newly diagnosed with lung cancer long after he or she got wise and gave up their cigarettes. Let’s not repeat those mistakes and regrets with e-cigarettes and vaping”.
Again, disingenuous to talk about ‘combustible liquids’; vapers do not ‘set fire’ to e-liquids, the whole point is to simply heat e-liquid to a temperature sufficient to release the nicotine with hardly any of the toxins you get by ‘setting fire’ to a cigarette. And just in case you missed it, let’s ram home the point linking vaping with cancer and conveniently ignore the many ex-smokers who say their lives have been turned around by making the switch.
What of the authors? Well the lead author works for the Lung Cancer Research Association, an American agency who have Big Pharma making up most of its corporate partners. Now far be it from me to cast aspersions, but Big Pharma, who produce NRT products, have been losing out Big Time to e-cigarettes. The New England Journal of Medicine published a UK study that reported the results of a one-year randomised, clinical trial in which e-cigarettes were compared to NRT to aid smoking cessation. The result: "The 1-year abstinence rate was 18.0% in the e-cigarette group, as compared with 9.9% in the nicotine-replacement group”. So you might expect that in the interest of smokers’ health, agencies like the American Lung Association would welcome the results of the study. Nope, as Dr Michael Siegel notes, it seems like they would rather smokers carried on coughing than use e-cigarettes to help quit: “We only support methods that are FDA approved and regulated. Switching to e-cigarettes does not mean quitting. Quitting means truly ending the addiction to nicotine, which is very difficult”. https://tobaccoanalysis.blogspot.com/2019/02/does-american-lung-association-really.html.
And if you look at the list of American Lung Association corporate donors, say hello to another list of pharmaceutical companies who would like nothing more than the death of the vaping industry.
And on the general issue of one hand washing the other, it is not only Big Pharma involved here; in the US, those health agencies, NGOs and individual academics most vocal in their opposition to safer nicotine products are also in receipt of huge amounts of federal funding, as detailed in this report by the US pro-free market lobbying organisation the Competitive Enterprise Institute called The Fear Profiteers: how e-cigarettes panic benefits health activists. The Executive Summary states:
“Instead of recognizing the historic opportunity e-cigarettes represent to displace traditional smoking, powerful charities like the American Cancer Society and the Campaign for Tobacco-Free Kids, state and federal health agencies, and some academics have condemned the proliferation of vaping products. Their influence on public opinion and public policy stems largely from their image as credible, apolitical entities motivated purely by an interest in protecting public health. As their approach to e-cigarettes demonstrates, this perception is inaccurate. In addition to their public health goals, health agencies and health charities’ activities are also driven by a need to defend and expand the financial resources they need to pursue their respective missions…non-profits—and to a certain extent, health departments—compete for charitable donations and sometimes government funding. The two basic strategies health charities and agencies employ to court funding are to: 1) raise the perceived need to address the health problem on which they focus; and 2) promote their organization’s comparative effectiveness in addressing said health problem. This approach to fundraising is generally uncontroversial in the non-profit arena, where organizations compete intensely in an environment where both attention and charitable dollars are limited. However, when an organization is part of a government agency or endorsed by government agencies, its efforts to raise awareness of an issue and its own clout can incentivize activities that clash with sound public health policy. Furthermore, using e-cigarettes as a case study, this paper demonstrates how this negative effect is magnified when health charities, federal health agencies and state health departments are financially co-dependent. Though perceived as independent the health charities, many of the nation’s most well-respected health non-profits are, in effect, arms of federal health agencies. Groups like the American Cancer Society (ACS) receive money from agencies, like the National Cancer Institute within the National Institutes of Health. As such, it is in ACS’ interest to support or even lobby on behalf of the National Cancer Institute as it seeks to sustain or increase the funding allocated to it in the federal budget. In turn, health agencies like the National Cancer Institute have an incentive to boost the reputation of their supporting health charities like ACS. Not only can these charities provide strong support during budget discussions, by echoing or even executing the Institute’s efforts throughout the year, they can make the Institute appear more effective and therefore more worthy of budget allocation”.
And along similar lines, I would draw your attention to this commentary published in the BMJ which celebrated the influence of civil society on global health policies:
“The disruption and challenges caused by neoliberal globalisation and the inability of global and national governing bodies to respond effectively has led to the emergence of new players, particularly civil society organisations. These groups have caused a disruption in global health governance by advocating for change in many areas of development, including poverty reduction, gender equality, and climate change”.
“The Declaration of Alma Ata in 1978 and the Health for All Strategy in 1981 enabled civil society organisations to work side by side with health professionals. This opportunity to have a key part in global health governance was apparent after the emergence and spread of HIV/AIDS in the 1980s when networks of people with HIV and civil society organisations formed advocacy groups to campaign on human rights issues”.
So far so good, and no doubt that civil society has made a huge contribution to global public health. But I noted with disappointment (although no surprise) the absence of any mention of drug harm reduction and all the pioneering advocacy undertaken by and on behalf of some of the most despised and marginalised communities on the planet. But just as depressing was the lauding of the role of civil society responsible for the orchestrating the Framework Convention on Tobacco Control. The FCTC was developed under the auspices of the WHO and the health ministries of the member states none of whom had much if any experience of drafting international legislation. Into the vacuum stepped those who were able to foist a rabid, moral agenda on proceedings which ultimately has led to a situation where ‘human rights’ ‘civil liberties’ and ‘health for all’ have all been undermined by the campaigns to outlaw safer nicotine products. The WHO might want to ape Donald Trump and build a wall to insulate FCTC delegates from the undeniable evidence of the significant benefit of switching for those who cannot or do not want to quit, but in doing so they are conducting a ‘War against Nicotine’ which like all such enterprises is doomed to fail while at the same time potentially condemning many more smokers than necessary to disease and premature death. How can this possibly be in the interests of global public health? There are no plaudits to be handed out to those complicit civil society organisations.
So back to The Guardian op ed. There are many UK health professionals working in the public sector who will see this piece and continue to be cautious and confused about recommending switching to vaping for those patients they see that really cannot quit. This is especially galling as the UK approach is underpinned by the pragmatic and proportionate evidence reviews of Public Health England and the Royal College of Physicians. The tobacco industry was very good at sowing this very same confusion as to the real damage that cigarettes cause. So, to echo the authors, let’s not make that mistake again. Comment might be free, but misleading public health messaging comes at a price.