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Harry`s Blog 33: Evidence and the long grass - Nicotine Science and Policy

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Harry`s Blog 33: Evidence and the long grass

As you can see, this is blog number 33 and so I hope I am not repeating this little anecdote, even though it does bear repeating.

There used to be a BBC TV political comedy called Yes Minister in which the senior civil servant Sir Humphrey Appleby was consistently trying to derail any initiative by his Minister Jim Hacker, which might not be in the interests of the civil service. One failsafe tactic, should the Minister suddenly announce such a move, would be for Sir Humphrey to say, ‘That’s a very brave decision, Minister’ At which point Hacker would turn pale and instantly drop the idea. Because no politician who is actually in power wants to be regarded as ‘brave’ as that invariably means a risky enterprise which could end in the sack, reshuffled to some low-level post, a loss of votes or even the loss of a parliamentary seat entirely.

So politicians invariably act in accordance with the cautionary principle and if possible kick tricky policy issues into the long grass for somebody else to choke on. And one very tricky issue right now is the evidence of long-term harm from e-cigarettes and similar products being considered in Estonia and Australia.

The Estonian parliament are debating proposals that would impose draconian restrictions on all aspects of e-cigarette availability. In attempting to head off these developments, the Estonian Union of Sellers and Users of E-Cigarettes have submitted two reports to the Estonian Parliament followed this April by a petition to parliament containing over five thousand signatures questioning the legality and substance of their proposals. This automatically triggers a parliamentary legal review.

Judy Gibson of the International Network of Nicotine Consumer Organisations writes, “The first hearing was held on the 18th September and the Estonian group gave evidence in supporting the need for proportional regulation. Whilst many were inclined towards the veracity of Public Health England and Royal College of Physicians’ risk appraisal, others were dissuaded by portents expressed by Dr Maris Jesse, Director of Estonian National Institute for Health Development and former Executive Board member of the WHO.” As they couldn’t decide between the conflicting sources of evidence, they decided to delay until this week on what is supposed to be a final decision. In this case, the grass is relatively short, and hopefully more sensible expert witnesses can come forward to make the case for harm reduction and head off a potential disaster for those wishing to switch away from smoking.

The situation in Australia contrasts with that in Estonia. In a land down under, vaping is banned. The Vaporised Nicotine Products Bill 2017, is a private senators' bill which seeks to exclude e-cigarettes from regulation by the Therapeutic Goods Administration in order to legalise e-cigarettes in Australia. The Senate Committee recommended that “the Senate does not pass the Bill until further scientific evaluation of the efficacy and safety of e-cigarettes and related products has been undertaken”.

http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/VaporisedNicotine/Report

Estonian policymakers appear to be considering all the right evidence, but are being swayed by what they would deem equally credible voices. Similarly, Australian Senators will have access to all the most compelling evidence, but will also hear from ‘expert’ naysayers who could be equally compelling. As I say politicians are incredibly risk averse; moreover, politicians often like nothing more than banning something. It does wonders for the sense of moral rectitude and presents to the media and voters the idea that a ‘problem solved’. Legalising something is another matter entirely.

Comparisons with the UK are illuminating. Here, politicians have not been involved in the process, meaning the evidence has not been comprised by political expedience. Instead it has been left it to health experts to assess the available evidence and devise appropriate public health responses, albeit that the UK has had to sign up to the TPD and no doubt PHE had internal struggles for its approach to prevail. And while both the National Institute for Health and Care Excellence (NICE) and PHE both observe that the jury is out on long-term effects of non-combustible products, the fact that we have not reached that unimpeachable moment of defining certainty, doesn’t stop these health bodies from endorsing such products as aids to quitting smoking or reducing the harm of cigarettes.

Of course, there is no accounting for how the media will report your work. NICE found itself on the wrong end of some misreporting when the Irish press claimed that draft NICE guidelines on smoking cessation services and interventions were warning GPs against promoting the benefit of e-cigarettes to smokers.

http://www.irishexaminer.com/breakingnews/world/call-for-users-of-e-cigarettes-to-be-told-little-evidence-of-benefits-or-harms-806640.html

The implication was that NICE was at odds with Public Health England on options for delivering smoking cessation programmes. In its recent report, PHE endorsed e-cigarettes saying, “Research trials and stop smoking service data returns both indicate that e-cigarettes can help smokers to quit, may be at least as effective as licensed medications and that an increasing number of people are choosing this option…Stop smoking services should offer an ‘e-cigarette friendly’ approach. This involves being open to the use of e-cigarettes by those who wish to do so, providing behavioural support and offering stop smoking medications alongside an e-cigarette if chosen by the individual”.

https://www.gov.uk/government/publications/stop-smoking-services-models-of-delivery

In a strongly worded rebuttal of the Irish story, NICE said ““These are new products and naturally results of long term studies are only now emerging - strongly reinforcing the view that e-cigarettes carry a fraction of the risk of smoking”

“We promote e-cigarettes as aids to stop smoking and when used in conjunction with other support, smokers have some of the highest success rates. Our recommendation is that people should receive advice on e-cigarettes so that they can make informed decisions on how to stop smoking”.

"E-cigarettes are now the most popular quitting aid in England with growing evidence of their effectiveness, with similar or better results than nicotine replacement therapies such as patches. A recent BMJ study estimated that, in England, e-cigarettes lead to 16,000 - 22,000 additional smokers quitting a year”

“Our guidance is draft and we are keen to get feedback on the use of e-cigarettes during the consultation.” https://www.nice.org.uk/guidance/indevelopment/gid-phg94

The FCTC has not been impressed by the creation of the Foundation for a Smoke-Free World (FSFW) and posted this statement

http://www.who.int/fctc/mediacentre/statement/secretariat-statement-launch-foundation-for-a-smoke-free-world/en/#

Nothing here should surprise anybody, but there have been some indications that not all FCTC members were monolithically opposed to the new products in pursuit of public health gains. Sadly whatever rickety bridge might have been built, construction has probably stopped with this re-iteration of implacable opposition:

“The tobacco industry is introducing new products in pursuit of profit rather than public health. For example, new “heat-no-burn” products contain tobacco and electronic nicotine delivery systems (ENDS) contain nicotine, an addictive substance regulated through appropriate policies under Article 5.2(b) of the Convention related to legislative and administrative measures”.

“Parties to the Convention have agreed to consider applying regulatory measures to prohibit or restrict the manufacture, importation, distribution, presentation, sale and use of ENDS, as appropriate to their national laws and public health objectives. If other novel tobacco or nicotine products emerge, the way that they are treated needs to be considered in the same way”.

Much has been made of the amount of money PMI have committed to the Foundation. By anybody’s calculation, $1bn us a huge pile of cash and left people wondering what PMI hope to achieve. But this is a spending commitment spread over twelve years and as Barnaby Page of E-Cig Intelligence notes, “10% of revenue is a fairly widely accepted yardstick for total spending on marketing, including PR, and it can be significantly higher in consumer industries. This is roughly 0.1% of PMI revenue, in other words 1% of that notional marketing allocation”.

This Bloomberg article kicks off with a comment on the PMI investment, but then goes on to paint what is still a sketchy future for Big Tobacco in the world of alternative nicotine products. Painting by numbers with lots of unfilled sections and not all of the colours available.

https://www.bloomberg.com/gadfly/articles/2017-09-20/philip-morris-and-the-slow-death-of-smoking

No doubt though that smoking is declining in many parts of the world, not least in Japan where the latest monthly sales data from Japan Tobacco must have made uncomfortable reading for shareholders. In August, the company cut its domestic sales forecasts as the big switch over to HnB products continued apace

https://www.jt.com/media/news/2017/pdf/20170915_02.pdf#

https://www.reuters.com/article/japan-tobacco-results/japan-tobacco-cuts-cigarette-outlook-as-smokers-shift-to-heat-not-burn-alternatives-idUSL3N1KH31E

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