My attention was caught this week by a series of exchanges focussing on whether nicotine was less addictive when delivered via an e-cigarette than a cigarette or whether you were simply swapping one equally harmful addiction for another. The conversation was sparked by Professor Linda Baud seeking materials to use in addressing barriers among smokers to switching away from cigarettes.
The word 'addiction' is heavily freighted with moral undertones. The original value free meaning of the word 'addict' was simply a citizen of Rome who was in debt and so went into service to work the debt off. From the 15th century, the earliest days of the introduction of tobacco into Western Europe, it was documented that many people who started smoking found it very hard to stop, but it was not attributed to any moral failing on the part of the individual. Similarly with alcohol, while there was widespread disapproval at the outcome of being drunk – rowdy behaviour and violence, there was little concern about the act of intoxication itself.
That all began to change during the 18th century, the Age of Enlightenment and Reason which coincided with the Gin Craze that rampaged through London from about 1720-1750. Religious commentary meshed with medical thinking from which emerged the idea that in the Age of Reason it was totally unreasonable that anybody should drink to the point of oblivion. They must somehow be of unsound mind, gripped by some Devil-driven disease. Crucial in this discourse too were the growing demands of industrialisation and the need for a responsible, sober workforce meaning much of the opprobrium and legislation concerning 'self-destructive' behaviours were aimed at working people.
Through the 19th century in line with important developments in pharmacology, epidemiology, public health and medicine generally, doctors became a well organised and influential middle class group in society who made 'addiction' a medical condition only they could treat. But for all the talk nowadays of the 'disease' of addiction - that moral paradigm hasn't gone away not least because it continues to undermine notions of freedom enshrined in western liberal capitalism.
There are probably as many definitions of addiction as there are those willing to proffer them. My own view is that if (for whatever reason) you engage in an activity (could be for example, drugs, alcohol or gambling) which pretty much absorbs all your waking hours to the severe detriment of relationships, family, job, study, physical and mental well-being and probably drains all your financial resources into the bargain such that you might have to resort to criminal activity however minor, then you and those around you have a problem.
This cannot possibly apply to nicotine as a discrete substance even when delivered in a cigarette. The problem with a regular intake of nicotine in a cigarette is all the collateral damage caused by smoking. What nicotine provides is not some debilitating dependency that robs people of a productive life, but – when delivered through HNB technologies – more like a pleasurable habit, one with potential to save millions of lives.
Given the powerfully negative cultural images addiction conjures up, it wouldn't be easy for those involved in promoting harm reduction to dissociate nicotine from the concept of addiction. But addiction brings with it much guilt and shame and so it would be a harm reduction measure in itself to convince smokers that there is no shame in using nicotine per se and that on the best evidence, the switch to e-cigarettes can only be beneficial.
And to those who continue to exploit that shame by playing the addiction card, I say there is no place for morality in evidence-based public health.
The new Director General of the WHO has been named as Dr Tedros Adhanom Ghebreyesus Special Advisor to Prime Minister of Ethiopia and former Ethiopian Minister of both Foreign Affairs and Health.
As if the WHO didn't have enough problems, most recently over profligate travel expenses (more spent than on AIDS, TB and malaria combined) and issues of fundamental structure and governance (http://www.reuters.com/investigates/special-report/health-who-future), even Ghebreyesus' appointment itself has raised concerns with accusations of genocide and human rights abuses although the Campaign for Tobacco Free Kids don't seem to have a problem.
With the new appointment thoughts turn to the continued secrecy and lack of transparency inherent in the FCTC Conference of the Parties whose next meeting is in Geneva in September. It was here in 2004 that the final framework negotiations took place whose Byzantine machinations were brilliantly captured by Greg Jacobs, the chief negotiator at the meeting in this revealing article from the Chicago Journal of International Law.
The Australian Federal Government has announced an ‘Inquiry into the Use of Electronic Cigarettes and Personal Vaporisers in Australia’. The Terms of Reference for submissions are:
1. The use and marketing of E-cigarettes and personal vaporisers to assist people to quit smoking;
2. The health impacts of the use of E-cigarettes and personal vaporisers;
3. International approaches to legislating and regulating the use of E-cigarettes and personal vaporisers;
4. The appropriate regulatory framework for E-cigarettes and personal vaporisers in Australia; and
5. Any other related matter.
The inquiry home page is: http://www.aph.gov.au/Parliamentary_Business/Committees/House/Health_Aged_Care_and_Sport/ElectronicCigarettes. Submissions need to be made online by the deadline of Thursday 6 July 2017 (AEST).
The implications of the FDA Deeming regulations get more bizarre with every passing day. PMI have submitted a staggering two million pages of evidence (what does that actually look like? Could you possibly read it all?) to bring iQOS to the US market. Even the Executive Summary is over 200 pages long. Here you go!
And for all that effort, the claims are pretty modest:
“Switching completely from cigarettes to the iQOS system can reduce the risks of tobacco-related diseases”.
“Switching completely to iQOS presents less risk of harm than continuing to smoke cigarettes”
“Switching completely from cigarettes to the iQOS system significantly reduces your body’s exposure to harmful and potentially harmful chemicals”.
A CDC survey of public views on the risks to children of second hand vaping didn't quite produce the results they were hoping for. The results of the study were as follows: "Overall, 5.3% of adults responded that second hand EVP exposure caused “no harm” to children, 39.9% responded “little harm” or “some harm,” 21.5% responded “a lot of harm,” and 33.3% responded “don’t know.”" CDC response was basically that people were misinformed, but I like to think that behind closed doors as the survey results were analysed, somebody in the CDC went into Homer Simpson mode, “Doh!”.