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s2smodern

JUUL e-cigarettes have taken the American e-cigarette market by storm, capturing over 70% of the US market in extremely short time. Because of the huge publicity generated and much media hand-wringing in editorials, features and op-eds (often quoting diehard anti-tobacco harm reduction activists about the alleged risk to young people), this has no doubt fuelled interest in these devices by the same cohort. Much the same happened in the UK regarding LSD in the 1960s and glue sniffing in the USA during the 1970s; moral panic followed by accelerated interest.

In the litigious-hungry environment of the USA, there have been legal threats made to JUUL, and they seem to have responded by claiming that they have a way of restricting access by young people through using a Bluetooth-enabled age-verification system. This might sound like a ‘good thing’, but is it?

There are so many ways that a teenager determined to vape on a JUUL could find to skirt around any tech system like this and if, with each (no doubt) well-publicised workaround, the company kept having to ramp up the obstacles to purchase such that even adults had to jump through hoops to buy the product, it is obvious what would happen, especially because there would need to be a data storage element that many, post-Cambridge Analytica, would find totally unacceptable.

From a purely public health point of view, JUUL don’t have to do this when virtually nothing is known about JUUL use among young people – patterns and prevalence of use, impact on health, relationship to other substances like alcohol, cannabis and smoking and so on. Instead the company has been bounced into trying to deal with some unknown problem, except to the extent that young people are using a product which is significantly less harmful that the cigarettes they might otherwise have been drawn to.

This week’s must read, with extracts courtesy of Clive Bates:

Comprehensive causal models and harm minimization principles should guide regulations on vapourizers, by Jean-François Etter, professor of public health at the Faculty of Medicine of the University of Geneva in Switzerland.

“The UK Royal College of Physicians concluded that: ‘Concerns over gateway progression into smoking are unfounded’…Public Health England concluded that: ‘a causal link [between vaping and smoking] has not been established and neither has progression to regular smoking’… and the US National Academies of Science, Engineering and Medicine concluded that: ‘e-cigarette use by youth and young adults increases their risk of ever using conventional cigarettes’, but added that: ‘it is unclear whether this increase in ever use results in an increased adult initiation rate’... These three authoritative reports suggest that strong statements about gateway effects should be avoided”.

“… if there is a causal pathway between vaping and smoking, a good response is to reduce youth access to cigarettes. To protect children against smoking we should, above all, reduce the number of adults who smoke. This can be achieved by traditional anti-cigarette measures and by maximizing the number of adult smokers who switch to non-combustible products. Protecting youth against hypothetical gateways should not be given absolute priority over helping adult smokers to quit”.

“A constructive public debate on the pathways between nicotine-delivery devices is threatened by a reluctance to express doubt and to change one’s mind, by loyalty to one’s tribe and by partial and ideologically biased views. To make things more complicated, results of studies of vaping and smoking in youth vary widely. A good predictor of a study’s results is the author’s opinion and past publications. The literature on gateway effects is contaminated by unreliable, ideologically motivated studies. Given the political value of the gateway theory, opponents of e-cigarettes will not stop using this theory, even if the science behind it may always remain elusive and biased”.

https://www.ncbi.nlm.nih.gov/pubmed/30066353 


You would think that if a significant number of those young people who were most likely to try e-cigarettes actually had the right idea about them, about the fact that they were less harmful than cigarettes and that the vapour does not present a risk to others, this would be something that researchers would recommend should be built upon. Alas no. The researchers in this study appear to be recommending that correct health information should be subverted.

“Addressing harm and benefit perceptions may be important for interventions designed to reduce e-cigarette use among adolescents”.

https://www.ncbi.nlm.nih.gov/pubmed/30031636 


For those of you who have no more drying paint that needs watching, there are now the papers for COP 8 to peruse. The FCTC Secretariat has produced a new review of safer nicotine products. While the WHO have no power to force Member States to do anything about e-cigarettes and similar, they clearly have a certain direction of travel towards prohibition.

One paragraph in their document reads,

While international scientific consensus was not yet reached on potential negative and/or positive impacts of ENDS, possible mechanisms for reviewing the evidence that was published by an independent body might help future decisions by governments in approaching ENDS, its regulation, and its place, if any, in smoking cessation. In this regard, the Convention Secretariat is exploring with the International Agency for Research on Cancer (IARC) the possibility, if funding is available, to prepare a monograph that studies the evidence around the health effects and policy impact of ENDS and to agree on a research agenda on ENDS and on the vast array of new tobacco and nicotine delivery products and systems that are taking hold in the global market”.

The International Agency for Research on Cancer, the so-called ‘independent body’ that is going to settle all the arguments about safer nicotine products, is in fact an agency of the WHO. So that’s OK then.

And then this little gem further down the document urging Member States to get tough with those dreadful potentially life-saving products that won’t cost governments any money.

“Despite ongoing discussions in the COP over the last 10 years with regard to potential approaches to regulate ENDS, there are still a large number of the Parties that are not yet regulating these products, with potential consequences with regard to increasing uptake by young people, the impact on existing tobacco control measures, misleading health claims and deceptive marketing strategies, and ultimately the lack of proper information to consumers”.

I would say ‘there are no words’, but there are. However, those of a nervous disposition may be reading this, so I will refrain.

http://www.who.int/fctc/cop/sessions/cop8/documentation_main_documents/en/


Interesting read about the global trade in illicit cigarettes and the impact of high pricing encouraging those at the bottom of society who smoke the most, to inhale products of highly dubious quality. But then again, even those cigarettes manufactured to the highest standards will kill off half of those who consume them. The WHO are set to introduce a Protocol to Eliminate Illicit Trade in Tobacco Products. This will probably be about as effective as the three UN treaties aiming to control the manufacture, sale and use of illegal drugs, not least because at the same time, the WHO through the FCTC encourage Member States to tax cigarettes to the hilt as one of the most effective form of tobacco control. Ummm…

If the problem is that serious, why not establish a new protocol aimed at encouraging a switch away from smoking altogether towards products that are demonstrably safer? Or maybe we should wait for the IARC to adjudicate. 

http://www.who.int/fctc/cop/sessions/cop8/documentation_main_documents/en/


It was reported in The Independent that lung cancer deaths among women were set to rise by nearly 50% by 2030. The study looked at data from 52 higher income countries. I don’t have access to the study, but the lead author suggested that while e-cigarettes might help, their use as quitting aids was “contradictory and scarce”. But surely the point is that it is possible deaths could be prevented even if women switch – they don’t have to quit.

https://www.independent.co.uk/news/health/lung-cancer-women-deaths-smoking-tobacco-industry-cigarettes-breast-cancer-a8471871.html

http://cancerres.aacrjournals.org/content/78/15/4436


And in a similar vein, while these authors admit that lung cancer is increasing around the world and impacts most heavily on marginalised groups, they don’t endorse the role that safer nicotine products might play in reducing the death toll. In the abstract they say, “The rapid growth of commercially available electronic nicotine delivery systems (ENDS) present challenges to public health for which little short term and no long term safety data is available” and only appear to go as far as quoting the CDC that safer nicotine products only ‘count’ as having public health benefit if the smoker is using them simply as a route to quitting altogether.

http://tlcr.amegroups.com/article/view/21996/16749


And finally…given all the pathetic ad hominem attacks on pro-tobacco harm reductionists by those pretending to be arguing for the benefit of public health, here is a thought from that paragon of openness and transparency Machiavelli, who in 1513 wrote that promoting innovation was dangerous to those at the forefront of it.