November 13th, 2015

Response to Professor Chapman’s blog about my views on e-cigarettes

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Personalised attack

Professor Simon Chapman of the University of Sydney has used his BMJ blog platform to mount a quite personalised attack on my views on e-cigarettes drawing bizarre conclusions from imagined inconsistencies in statements I made about completely different things separated by 15 years and a lot of change. I’ve submitted a comment to the BMJ, but for all I know it will be held in moderation for days while the blog is circulating freely. So here is a copy of my attempt at a dignified response. 

Professor Chapman’s blog is largely based on comparing what I said in a report for Action on Smoking and Health (ASH) in 2000 about the conduct of tobacco companies with what I and many others are saying now about e-cigarette advertising. The key weakness in Professor Chapman’s argument is that the statements he compares were about two different things in a completely changed context.

My 2000 ASH report “PR in the Playground” was not just about tobacco companies: it was mainly about the useless and cynical youth anti-smoking initiatives run by tobacco companies. Tobacco companies running campaigns to persuade young people not to smoke were never going to be convincing or effective and that report shows why. They were mainly about protecting the reputation of tobacco companies – hence the ‘PR’ in the title. I haven’t changed my views about those programmes one bit, though I don’t know if they still exist.

But e-cigarette companies do not have programmes like this to my knowledge and Professor Chapman doesn’t suggest they do. My recent statements were about e-cigarettes, not cigarettes – another important difference. So he is comparing statements I made 15 years ago with statements made recently about something completely different in a radically changed landscape: there were no e-cigarettes in 2000. It’s not that surprising the statements look different.

I hope that Professor Chapman is fully aware of the potential dangers built into the positions he holds. It would be a major public health error to treat cigarettes and e-cigarettes the same way, given the very significant differences in risk – e-cigarettes are likely to be at least 95% lower risk than smoking, based on what we know of the toxic constituents of vapour. For example, an important effect of banning e-cigarette advertising could be to protect the incumbent cigarette trade from competition from a disruptive low-risk technology that helps people to quit smoking – thus increasing harm. In the UK, we have evolved a quite pragmatic approach to controls on e-cigarette advertising, which is similar to that used to control alcohol advertising. You don’t need a total ban to deal with the odd rogue advertisement (and it will always be possible to find these in any sector). The UK Committee on Advertising Practice reports that the e-cigarette code is working well and shaping the behaviour of advertisers in the way intended.

We rightly ban tobacco advertising in the EU because smoking kills 700,000 EU citizens per year. But no such justification exists for banning e-cigarette advertising. The most likely effect of e-cigarettes is to reduce the smoking-related death toll in future – a negative death toll – assuming they are allowed to compete.

The problem of unintended consequences goes beyond banning e-cigarette advertising. Much of the hostility towards e-cigarettes in the field of tobacco control, if translated into policies, misinformation or taxes, could have the effect of protecting cigarette sales and supporting smoking. I hope Professor Chapman will reflect carefully on what harms might be caused if his ideas are taken seriously by policy-makers.

I also made what I think is a reasonable point about the incentives of the companies involved: that the e-cigarette sector has a very large market of adult smokers to pursue as their potential customer base (this also applies to the tobacco owned e-cigarette companies who are fighting over market share). The data show that their customers are overwhelmingly adult smokers. The e-cigarette sector is small in every country compared to the cigarette trade (about $6 billion globally compared to $800 billion for the tobacco trade) so there is plenty of room to grow by eating into the cigarette trade. These companies would create unnecessary risks for themselves if they targeted teenagers, and they have no need to.

Even if not targeted, some teenagers will use these products. Most public health experts are familiar with the idea that some adolescents engage in risky behaviours and try adult things, and I hope that isn’t a revelation to anyone in the field of tobacco control. The data show that the teenagers who do use these products are almost all smokers already or have ‘risk factors’ that mean they are likely to become smokers. To the extent it is displacing smoking, e-cigarette use may be creating a health dividend. It’s too soon to say if that is actually happening, but the trends are largely consistent with that effect and Professor Chapman should expand his thinking to accommodate that possibility.

As far as consistency is concerned, in 2000 while still Director of ASH I was open-minded about the concept of the tobacco market evolving to low-risk nicotine products and even envisaged the challenge that this would create for some factions in the public health establishment. See my paper ‘What is the future for the tobacco industry” from Tobacco Control journal in 2000 and especially the section “How can the tobacco market evolve“, in which I imagine the rise of products a bit like e-cigarettes…

Imagine a hypothetical new product—let us call it “Satisfaction”. Assume it has the nicotine delivery of a Marlboro cigarette—not only the same dose of nicotine but the same speed of action and “impact”. To make it palatable it has been flavoured, perhaps with something fashionable like tequila. As an ironic marketing gambit, a hard living cadaverous rock star has been enlisted to endorse the product. It is packaged like “poppers” (capsules of amyl nitrate) and sold initially in bars and clubs to give it an “underground” feel. Of course, “Satisfaction” is powerfully addictive and the nicotine has effects on the heart and other health consequences. It appeals to the young and there is concern that teenagers might start to use it. In many respects, it is similar to a Marlboro cigarette, except that it does not expose the user (or people nearby) to inhalation of 4000 products of tobacco combustion and greatly reduces the risk of disease associated with long term nicotine use. Even if it is not entirely safe, “Satisfaction” is far less harmful than smoking tobacco.

What would you think about this product? Would you fight to ban it, or fight to have it introduced? I would want it introduced. It is an alternative that introduces no new risks that are not already present with cigarettes, but greatly reduces smoking related health risk. The truth is, however, that we are unlikely to be asked. No pharmaceutical regulator would approve “Satisfaction”, and knowing the impossibility of bringing such a product to market, no food or drug company would even begin any sort of development.

Underpinning this view is a clear distinction between the use of the drug nicotine and the harm caused by its manner of delivery. This is a crucial distinction—health promotion efforts have implicitly tried to tackle the harm and the underlying drug use simultaneously. This approach has had some success with some groups in some societies. The problem is the remaining people who continue to take nicotine by smoking tobacco. For them, it is possible to tackle the harm caused by the manner of delivery independently of the drug syndrome. This is not to say that nicotine dependence should not be tackled, but “drug problems” are social phenomena and should be tackled by addressing the underlying socioeconomic and cultural causes, backed up with treatment for dependence.

My article from 2000 is not perfectly correct about the rise of e-cigarettes, but as a bit of crystal-ball gazing it is not a bad account of what has come to pass. Neither is it inconsistent with what I’m saying now. I was warning even then that we would need to put health first if the market evolved in this way, which it duly has done: leaving the much of the tobacco control community confused about its mission.  What I said in 2000 about the future of the nicotine and tobacco market is, I think, a fairer test of consistency of my approach to e-cigarettes than what I said at the time about something completely different.

Regrettably, this blog contains unfounded innuendo about my purpose that readers should discount. I don’t wish to engage Professor Chapman in personal animus, but I would like to explain my own motivation. I believe the ‘harm reduction’ agenda is a legitimate strategy in drugs, sexual health, alcohol and other fields within public health – and there is every reason to apply it to smoking. I have been consistent about this since 1998. I put a lot of time into this issue because I believe it has the potential to avoid hundreds of millions of premature smoking-related deaths in the 21st Century by making the cigarette obsolete for many or most users. Furthermore, I think it is consistent and synergistic with legitimate evidence-based tobacco control policy – the more you press people to stop smoking with punitive or coercive measures, the more important it is to have somewhere for committed or addicted smokers to go. That’s an ethical argument that tobacco control advocates would do well to embrace if they wish to succeed in their mission.

End of posting.

18 comments to Response to Professor Chapman’s blog about my views on e-cigarettes

  • Great information. Lucky me I discovered your website by accident (stumbleupon).
    I’ve book-marked it for later!

  • Bill Godshall

    The BMJ Tobacco Control blog editor(s) censored (i.e. refused to post) the comment I tried to post several days ago at http://blogs.bmj.com/tc/2015/11/13/e-cigarettes-and-children-advocates-walking-on-both-sides-of-the-street/

    So I eliminated two sentences that appropriately criticized Chapman and BMJ, added several sentences discussing the numbers, and tried reposting the comment that appears below (now awaiting either posting or censorship by BMJ editor(s) and/or Chapman).

    According to the growing mountain of scientific and empirical evidence, nicotine vapor products (aka e-cigarettes):
    – are 99% (+/-1%) less hazardous than cigarettes,
    – have never been associated with any disease,
    – are virtually all (i.e. >99%) consumed by smokers and by ex-smokers who switched to vaping,
    – have replaced more than 5 Billion packs of cigarettes worldwide in the past eight years,
    – have helped several million smokers quit smoking, and have helped several million more smokers sharply reduce their cigarette consumption,
    – are more effective for smoking cessation than MHRA/FDA approved nicotine gums, lozenges and patches (which have a 95% failure rate),
    – pose fewer safety risks than MHRA/FDA approved Verenicline (Champix/Chantix/),
    – have never been found to create nicotine dependence in any nonsmoker (youth or adult),
    – have never been found to be a gateway to cigarette smoking for anyone,
    – emit trace levels of nontoxic aerosol that poses no harm to nonusers, and
    – have further denormalized cigarette smoking (as youth and adult smoking rates and cigarette consumption have declined every
    year in the US and UK since vapor sales began to skyrocket).

    Even if vapor products were only 95% less harmful than cigarettes (which Public Health England has estimated despite no known deaths from vaping), the only way vapor products could harm public health is if 20 times more never smokers (than current smokers) began daily vaping.

    But nobody has yet to identify even one never smoker (anywhere in the world) who has become a daily nicotine vaper. And for the past five years, US DHHS has rejected requests to include a question about daily vaping in their surveys (that only inquire if people ever heard of, ever used, and/or used an e-cig in past month).

    Meanwhile, virtually every survey (worldwide) inquiring about past month, current or regular use of vapor products has found that smokers are at least 20 times more likely than never smokers to use vapor products.

    In sum, its mathematically impossible for vaping to harm public health (even if all never smokers in the US and UK began daily vaping, and if no more smokers in US and UK began vaping).

    BTW Thanks to vaping, the US adult daily cigarette smoking rate declined to 12.9% in 2014, which is lower than Australia’s rate.

  • […] Chimpman has even taken on Clive Bates. Here’s Clive’s response. […]

  • Mark Magenis

    Fingers crossed that A Billion Lives gets the go ahead for Sundance 2016, it should get the year off with a bang.

  • Irish Lass

    Can the BMJ not be held to account for the rubbish it prints? Where are the doctors to challenge this rag’s editors?

    And where is the investigative journalism to investigate and expose Simon Chapman and his like for what they are doing?

    Are all doctors and journalists so under-the-influence of the ANTZ that they have actually been taken in? Are they too lazy to protest? Or are they scared, for their careers, to turn over these stones and expose the nasty creepy crawlies that are lurking there?

  • Mr. Blog Dog

    It would seem that the moderators on the BMJ blog are in full censorship mode. One of my comments and two other comments which were all valid and civilised in tone, have been at first allowed, and the removed. And my comment (below) didn’t even pass the first hurdle with the BMJ censors.

    It could be a technical glitch, but very unlikely.

    ——————————

    QUOTE: “Bates knows perfectly that tobacco companies understand the importance of smoking uptake by children to their future, but seems to believe that such a thought has never crossed the minds of ecig manufacturers.” – Simon Chapman

    The latest CDC survey [1.] (published in October, 2015) involving 36,000 participants, found that e-cigarette use was largely confined to smokers and former smokers. In fact, the survey found that only 0.4% of never smokers went on to become regular e-cigarette users. If e-cigarettes companies as the professor implies, are marketing to non-smokers, they are doing a terrible job of it!

    [1.] http://www.cdc.gov/nchs/data/databriefs/db217.htm

    • John walker

      Actually a more likely source of growth in demand for ‘ecig’ like devices is cannabis related, according to a number of studies cannabis smoking is these days more widespread than tobacco -am told that’ vaping ,the stuff is better and more economical .
      And vale type devices also look likely as delivery systems for the medical forms of cannabis as well.

  • Attila Danko

    Nicotine ecigarettes/eliquids are still banned in Australia. The black market is huge though.

    • Jude

      Perhaps they are trying to pretend that vapers and vaping doesn’t exist, like they are doing with the tobacco black market, (also huge and growing). Chapman’s university put out this article on people quitting smoking, and there wasn’t a single mention of any THR product, such as e-cigarettes or snus.

      https://theconversation.com/despite-help-on-offer-many-smokers-prefer-to-quit-on-their-own-heres-why-41749

      This article is by Chapman, supporting the proposed large increase in tobacco taxes.

      https://theconversation.com/big-tobacco-of-all-the-concerns-there-is-one-taxation-which-alarms-us-the-most-50580

      In my view this shows very well the reasons behind Chapman’s hatred of vapers and vaping, and why he doesn’t want THR products readily available, and easily accessible in Australia. Chapman was well funded under the ALP government, but without the political protection of the ALP he has taken some heavy hits to his status and reputation. This is just more of the “quit or die” ideology, or should I say, “pay excessive taxes, quit or die”. Linking this tax increase to education is incredibly hypocritical, but then this is what I’ve come to expect from politicians, and those that feed from the government trough.

  • NutmegJunkie

    “…nicotine might be causative in psychosis. Such serious considerations demand that trite dismissals of nicotine as being as benign as “like drinking coffee or something” be condemned.”

    Another gaffe. There is an equally (if not more clearly established) relationship between caffeine use and psychosis[1].

    I also noticed that the systematic review he cites as evidence re: the ‘hazards of nicotine’ is actually a review of possible link between smoking tobacco and psychosis (not nicotine on its own).

    1. http://scholar.google.com.au/scholar?hl=en&q=caffeine+psychosis&btnG=&as_sdt=1%2C5&as_sdtp=

  • Donna Darvill

    Thanks Clive,

    Professor Chapman should have a look in his own backyard first. In a state where nicotine ecigs are illegal and vape shops can be counted on one hand, “ever use cigarette smoking” among youth is at an all time high. According to 2014 data, 75% of Year 11 students and 49% of Year 8 students have smoked a cigarette.

    Tobacco Control’s message, plain packs, exorbitance taxes, lack of advertising and denormalisation of smoking and smokers is clearly not working among our youth.

    https://www.data.vic.gov.au/data/dataset/vcams-proportion-of-young-people-who-have-ever-smoked-cigarettes

    I know “ever use” doesn’t mean most will go on to be lifetime dependent smokers but I tell ya what, in this day and age it’s certainly not looking like the traditional TC methods to lower uptake are working here.

    I reckon Harm Minimisation via Vaper Products might just be the answer but who I am to say, I’m just a mere anecdote.

    Thanks for all that you do Clive

    Donna

    • John walker

      Donna hi , small point but ,I think that chapman lives in NSW? In NSW under a recently passed Act ,the sale and use of ecigs to adults is quite legal and they are not subject to the restrictions on where they can be used, that Smoking is subject to .That must really anoy Chapman. Have a feeling that the PHE ,Clive et al , had a bit of influence on the passage of the act, hence Chapman’s anger.

      BTW Australias libel laws are notoriously tough, think that what Chapman has written could possibly be verging on , damaging to good name and professional reputation under our laws,

    • Jude

      Hi Donna,

      I saw the report you referenced, and it was quite surprising, if just for the fact that it got published in the first place. Usually anything that shows the tobacco control industry in a bad light is censored.

      Chapman is a coward, using the BMJ blog to try and cast slurs at those who don’t agree with him, in this instance Clive Bates is the target, but its par for the course with this particular ANTZ. Chapman has had several heavy blows to his “reputation” and “honesty” lately, and I think this is just him trying to gain back credibility, although this is likely to have the opposite effect.

      Chapman has recently put his support behind a proposal by the ALP to tax smokers even more, to pay for some of their education reforms, and as vaping, if allowed to compete with tobacco smoking, will mean there are far fewer smokers to pay these taxes, it is understandable that Chapman will fight tooth and nail to see them remain either banned from sale or extremely hard to access. It seems this is purely political, and financial, but then it never has been about health.

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