June 5th, 2013

Some truth about e-cigarette regulation and the ‘appalling’ F-grade presentation of the WHO

A public health academic is forceful and direct with the misguided opponents and over-zealous regulators of e-cigarettes. He describes the presentation of World Health Organisation’s Roberto Bertollini to a  European Parliament workshop as ‘appalling’.  This is a measured,  compassionate, but quietly angry and exasperated interview by one of Europe’s leading experts on e-cigarettes, Professor Jean-François Etter.I hope everyone involved with the e-cigarette policy debate will take 5 minutes to view this – it says pretty well all that needs to be said.  Some quotes I’ve drawn out:

Mr Roberto Bertollini made a presentation at the EU workshop which was appalling. His presentation consisted in cherry-picking negative studies,   studies that show that e-cigarettes are bad, and deliberately omitting studies that suggest that e-cigarettes could be useful in helping people quit smoking.  So I confronted him on that and he didn’t like it… 

This is true – Bertollini’s presentation was truly appalling pseudo-science.  But I would go further – there was great exaggeration of the negatives and over-emphasis on minuscule risks in comparison with continued smoking, and deep confusion between hazard and risk.  This sort of presentation spreads fear and misinformation and supports the cigarette market by smearing a credible competitor.  Tom Pruen of ECITA has done an excellent critique of Bertollini’s presentation: why the WHO is not qualified to attempt to educate people about electronic cigarettes. Etter expresses his despair at such poor homework: 

If a student had presented such a work to me I would have given him a very bad grade.  WHO after all is here to protect the health of the public, so by taking such an approach they are not doing their job. 

If only it mattered as little as a student assignment…! This was the privileged position of being able to make a presentation to Europe’s legislators, who are deciding how to regulate these products.  The way we give WHO a bad grade is to suggest that governments give them less money and more direction.  Having established who not to listen to, Etter moves on to what not to do:

It would be a mistake I think to regulate these products as medications, and if they were regulated as medications this would limit access to the product too much and cause many deaths.

This is absolutely right.  Current e-cigarette products are probably about 99% less dangerous than cigarettes (you can say that simply by virtue of the chemistry of their ingredients and physics of how they work).  The public health case is best served by having the greatest number switch from smoking, not from regulating them from 99% to 99.5% safer but much less appealing as a result.  Medicines regulation raises costs, imposes compliance burdens, slows access to market, inhibits innovation, applies dullness-inducing design and marketing restrictions and will largely advantage the cigarette industry by shielding it from competition from better products.

There is a debate between policy-makers who are very conservative and very risk averse, and are ready to regulate these as medications, and the public who appreciates the product and uses it. 

Again, he is spot on.  Regulators instinctively care more about small things that might go wrong than big things that are going well.  The public are much more interested in the huge personal benefits that arise from switching than being ‘saved’ by regulators.  What is surprising is that supposedly ‘progressive’ socialist and green politicians lead this heavy regulation mindset in the European Parliament. Given that long-term smoking is closely linked to poverty and drives health inequalities, you might expect leading politicians like Glenis Willmott (Socialists) and Carl Schlyter (Greens) to listen a bit harder to the public rather than health lobbyists and not be so indifferent to the health of people they represent.  Liberals and Conservatives have understood that a it s better to encourage these products than to smother them.   Etter then turns his fire on the public health community.

Astonishingly, the most vocal opponents of e-cigarettes are people from the public health community, who perhaps don’t understand what is at stake, and just don’t like the product because it looks too much like a cigarette. 

Etter is so right on this… many (but definitely not all) in the public health community don’t like these developments at all.  That’s because they have lost sight of their real goal – which is to reduce cancer and other diseases, not just to campaign for tobacco control policies.  But e-cigarettes have arrived like an insurgency, coming from nowhere creating opportunities for smokers rather than restrictions.   Public health workers have played no part in this uprising, they haven’t ‘approved’ the products, they don’t know much about them or why they are popular, and most importantly they aren’t in control.  I think they are professionally affronted and are responding with a regulatory and rhetorical broadside to fight back.   So Etter states the problem this causes:

If regulators could let the market evolve without regulating it too much and without regulating it unjustly… because currently people who are addicted to cigarettes are condemned to use tobacco, these laws arguably kill millions of people. They are absurd because they block every competitor to cigarette makers. So there’s a need to let competitors to enter the nicotine market so more people will switch from smoking to e-cigarettes and this will save many lives. 

Where regulators are trying to ban or over-zealously regulate e-cigarettes, they really are doing harm.  Which gets back to points I’ve made a number of times [eg here and here]: WHO and many of the public health campaigners  might as well be working as lobbyists for the dinosaurs in cigarette industry*, busily causing more death and disease.  The effect they would have if they got their way is the exact opposite of the one they are supposed to want.

* By the way this comparison with the health lobby is not intended to be unfair to: a) dinosaurs; b) those people in the tobacco industry who understand what this means for consumers and have been buying or developing e-cigarette or smokeless tobacco businesses. There aren’t many ethical things that a tobacco company can do at scale, but that is one of them.

WHO we have a problem… Bertollini isn’t the only one from WHO giving bad advice to the European Parliament. I am still hoping for a response to my critique of the recent presentation of Kristina Mauer-Stender: Are you being manipulated: the wisdom of the WHO examined.  At global level, the WHO is especially misguided – see this open letter to delegates to the tobacco control convention.

And… thanks to SWOF for the video.

13 comments to Some truth about e-cigarette regulation and the ‘appalling’ F-grade presentation of the WHO

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