Language matters. In my last blog, I highlighted the campaign by Cancer Research UK to counteract the idea that e-cigarettes are just as dangerous as smoking.  And part of the problem resides in conflation of ‘smoking’ and ‘tobacco’ when communicating about smoking-related death and disease and more generally the denial of accurate public health information to smokers.

Lynn Kozlowski and various colleagues have written on the ethics and legality of withholding or distorting health information

Jonathan Adler from the Case Western University of Law, takes the issue a step further arguing the ban on allowing the vaping industry to impart evidence-based health information to consumers might be in violation of the right to free speech under the US Constitution.

He concludes:

“The government has a significant interest in ensuring that producers do not misrepresent their products or make unsubstantiated product claims. But under current First Amendment jurisprudence, this does not allow the government to prohibit truthful claims about otherwise legal products. If the FDA is concerned that e-cigarette manufacturers might oversell their products’ benefits or mislead consumers, it can require disclaimers and qualifications, much as is done with nutritional supplements. What the FDA cannot do is simply require manufacturers to be silent. Such a position is contrary to the First Amendment — and risks undermining public health”.

From the comments, some believed that Professor Adler was advocating an unregulated marketing free-for-all which he categorically denied, simply that regulations currently in force are more than just ‘not fit for purpose’.


But, Joel Nitzkin, senior fellow for tobacco policy at the R Street Institute, does not believe this conflation of smoking and tobacco is just sloppy language:

“As I understand it, there are two root causes for this error in attribution of risk.

The first is the "health education" generated by CDC and others, over a period of decades, to convince people that switching from cigarettes to smokeless tobacco would simply trade a lung cancer risk for a mouth cancer risk of similar magnitude.  Thus, with both combustible and non-combustible tobacco posing similar risks -- the public health program should be against all things tobacco.

The second is that, long ago, tobacco control has morphed from a public health enterprise to prevent illness and death to a moral crusade against evil tobacco companies intent on addicting our children to a deadly substance. This, in turn, hearkens back to the 18th Century concept of tobacco as an evil weed.

Thus, many tobacco control leaders (CDC, NIH, FDA, Tobacco Free Kids, the paediatricians, lung and cancer societies and others) would see any proposal to change the goal from "tobacco-free" to "smoke-free" as a threat to their entire enterprise. This is not to say that such a change cannot be made -- it is to say that tradition, not science, currently drives tobacco control policy. "

Heat not Burn (HnB) products are relatively new products to market and have already achieved some spectacular success particularly in Japan which has seen cigarette sales fall dramatically as a result. The general assumption is that while not as safe as e-cigarettes because they contain tobacco which is heated, the degree of heating is nowhere near as high as for cigarettes and so the release of toxins is significantly reduced. So far most of the data has come from the companies themselves, a point noted by the UK Committee on Toxicity, who recently issued a toxicity evaluation of HnB products

They tested two products, one where tobacco is directly heated to produce a vapour and a second where the device produces a vapour from a non-tobacco source and then is passed over tobacco in order to flavour the vapour. The first heated tobacco to 350 degrees while the second only to 50 degrees, leading the committee to conclude that the reduction in exposure to harmful compounds was 50% and 90% respectively compared to a cigarette burning at 800 degrees or more and so pose less risk to those switching and to bystanders. While hardly a ringing endorsement of HnB due to a lack of independent evidence, the statement does acknowledge ‘a likely reduction in risk’ compared to cigarettes.


I do have a dilemma about publicising what is rightly dubbed in this field ‘junk science’ – the studies that purport to show the evils of safer nicotine products, but whose methodology or conclusions are rapidly and forensically trashed by wiser heads than mine. On the other hand, it is probably helpful (tell me if it isn’t) for readers to be drip fed some rubbish for use as ammunition as people see fit, although I will refrain from mentioning any more comments from certain notorious individuals as just not worth my fingers on the keyboard. So here goes:

There was a new report from the University of California in San Francisco which claimed to have conclusive evidence of the gateway effect. This was reported in the UK in The Sun newspaper, a Murdoch comic that once ran a front-page headline about a British comedian, “Freddie Starr ate my hamster”, so clearly a serious publication of record. Sufficed to say, the report demonstrated no such thing as explained by Professor Brad Rodhu,

Under the headline ‘OOPS’, Professor Rodhu reveals that  “the researchers report that teens who had ever used e-cigarettes, hookah, other combustible products or smokeless tobacco at the baseline survey were two or three times as likely to be smoking cigarettes (in the past-30 days) one year later than those who had not tried any tobacco product.  Those who had tried two or more products were 3.8 times more likely to be smoking.”

However, the authors (including guess who?) “omitted information that is critical to putting their findings in perspective” . Although teens trying other tobacco products were more likely to smoke, the majority of new smokers after one year came from the group that had not tried tobacco at baseline. “ (my emphasis).

Commenting on the post, Dr Roberto Sussman from Mexico found similar flaws in another study alleging gateway effect where evidence was hidden or ignored. The authors reported that “vaping but not smoking kids at baseline in 2015 had a 40% risk of becoming "conventional" smokers (at least a cigarette in the last 30 days) in 2017 in comparison with never smokers at baseline. When you break down the demographic data, it turns out that of the 247 conventional smokers in 2017, 223 were never smokers in 2015 and only 24 (about 10%) had tried vaping but not smoking in 2015.

As Dr Sussman says and as is often the way with studies like this, you have to dig into the data to expose the detail and reveal the inconvenient truth. And how many people will bother to do that? So actually, I have answered my own question. Yes, it is worth arming people with the knowledge that the truth is out there if not obvious and transparent.


And finally…the WHO recently published a report on smoking in China. The key messages of the report highlight the appalling toll that smoking cigarettes inflicts on the country:

  • With 315 million smokers, China is the world’s largest producer and consumer of tobacco. In 2014, 44% of the world’s cigarettes were consumed in China.
  • Tobacco is on track to claim 200 million lives in China this century – predominately among poorest and most vulnerable people. In other words, current tobacco policies are negatively affecting China’s poor the most.
  • The total economic cost of tobacco use in China in 2014 was approximately ¥350 billion (Chinese yuan), or about US$ 57 billion, a 1000% increase in total economic costs since 2000.

Yet without a hint of irony, the WHO includes in its recommendations for fixing this that a ‘firewall’ is built between the state tobacco control system and the tobacco industry in line with Article 5.3 of the FCTC. Umm….except the state has a monopoly on cigarette production as does the government in Thailand which just happens to be the location for the  new WHO knowledge hub for Article 5.3.