I am indebted to my good friend Roberto Sussman for the title of this blog. Roberto lives in Mexico and is an unlikely combination of astrophysicist and ardent, eloquent tobacco harm reduction activist. He gave a speech in London on 23rd January 2020 at the launch of the Tobacco Harm Reduction – the Right to Health briefing published by Knowledge•Action•Change and available here: https://gsthr.org/report/2020-briefing-paper
Roberto was making the point that in many western countries, people tend to believe messages from public health because since the late 19th century, public health has delivered in terms of improving health – through, for example, policy drives to improve water quality and sewage, and public messaging about personal hygiene, all in the service of combatting deadly infectious diseases. In the realm of non-communicable disease, few people now believe that smoking is not damaging to health. So, when medical authorities in these countries send out the message that there is no evidence for relative the safety and efficacy of safer nicotine products (SNP) over cigarettes, they are believed.
However, in Latin America, Roberto said that public health is not so readily believed because the people see little evidence of public health progress in other areas. The situation in Africa has been more extreme. There are recent examples of public health workers being attacked trying to vaccinate at-risk populations against Ebola. During the presidency of Thabo Mbeki in South Africa, there was official hostility to the well-established medical evidence that HIV caused AIDS to the extent of denying suffers access to antiretroviral drugs.
More often than not then, the angels are right. But what happens if they are not only wrong, but deliberately so – and when in fact it is the devil telling the truth? Who do people believe?
The most egregious example of angelic falsehood is the attitude of the WHO towards tobacco harm reduction through the use of SNP such as e-cigarettes, heated tobacco products and Swedish-style smokeless snus. There is a wealth of independent evidence that, compared to smoking cigarettes, these products are much safer in that they do not expose the user, to any significant degree, to the toxins emitted by cigarette smoke. The simplest experiment demonstrates this:
Nicotine of itself does not cause any of the illnesses associated with smoking, is no gateway for young people to move onto cigarettes and is more effective that NRT or other medications for those looking for an off-ramp from smoking. And given the relatively benign nature of nicotine, even the notion of ‘addiction’ is seriously over-played when compared to those drugs we normally associate with that term.
Yet, despite all the evidence, the WHO and other so-called public health authorities constantly muddy the waters with misinformation and then declare that because of the confusion they and others create, we cannot be sanguine about the relative safety and efficacy of these products. The WHO recently published a ‘fact’ sheet about SNP which is full of bad and misleading information aimed at deliberately influencing decisions about banning products of which they disapprove on quasi-moral, religious and political rather than public health grounds. Here is a taster of its messaging on the alleged baleful effects of what it calls Electronic Nicotine Delivery Systems (ENDS):
“ENDS emissions typically contain nicotine and other toxic substances that are harmful to both users and those exposed to the vapours second hand”.
Nicotine is not toxic in e-cigs and there is no evidence of harmful effects due passive vaping.
“There is no doubt that they are harmful to health and are not safe”.
Typically, they swerve around making comparisons with cigarettes in order to mislead. When you examine the comparative evidence, the truth is obvious.
“Exposure to nicotine can have long-lasting, damaging effects”.
But those who oppose tobacco harm reduction declare that we don’t know the long-term effects – which is true. But we do know enough to make the point about significant relative safety compared to the worst health impacts of smoking. Here the WHO want it both ways.
“Young people who use ENDS are also more likely to use conventional cigarettes, cigars or hookahs”.
They are also more likely to smoke dope, drink alcohol and get up to all sorts of other activities parents don’t like. This is not the same as saying SNP lead to smoking as there is no evidence of this at all.
“ENDS increase the risk of heart disease and lung disorders. For pregnant women, ENDS pose significant risks as they can damage the growing fetus”.
Where disease has been demonstrated in SNP users, it usually takes no account of the fact that these people have switched after years of smoking and are now suffering the diseases of that smoking. There is no real world evidence of fetal damage.
“ENDS also expose non-smokers and bystanders to nicotine and other harmful chemicals”.
Exposure in and of itself does not demonstrate harm and there is no evidence of harm anyway.
“On 17 September 2019, the United States Centers for Disease Control and Prevention activated an emergency investigation into links between ENDS use and lung injuries and deaths. By 10 December 2019, the USA reported more than 2409 hospitalized cases and 52 confirmed deaths”.
The WHO knows well enough that these incidents have been linked to the vaping of cannabis products, not industry-standard e-liquid.
“For tobacco users looking to quit, there are other proven, safer and licensed products, such as nicotine replacement therapies (such as patches and gums), as well as quit lines, mobile messaging and specialized tobacco dependence treatments”.
So if these interventions are so successful, why does the WHO admit that the world is still in the grip of a smoking epidemic and that many countries are unable provide these services?
Anti-tobacco harm reductionists claim that those academics, clinicians, and campaigners who support the use of SNP are all in the pocket of the devil (aka Big Tobacco) and go out of their way to deny free speech and threaten the ruination of careers. It is said the devil has all the best tunes. In this case, he also has the best evidence whereas the angels have clearly fallen and are not to be trusted.