May 23rd, 2016

Who or what is the World Health Organisation at war with?

Dr Chan is at war

Dr Chan is at war – but who or what is she fighting?

The World Health Organisation does a good line in war-like rhetoric when it comes to tobacco policy. But what is it actually at war with? In this post, I examine the confusion in ‘tobacco control’ about what it is actually trying to achieve.

WHO’s war on Big Tobacco

Like many in tobacco control, WHO mistakenly believes it has been successfully battling the tobacco industry and has them on the run.  This is an example of WHO’s bellicose rodomontadeWHO’s strategy to put Big Tobacco ‘out of business’.

The Hong Kong native who has run the U.N. body for the past decade, Margaret Chan, takes evident pride in being called Big Tobacco’s public enemy No. 1, saying that her goal is to “make sure that the tobacco industry goes out of business.”

And Roberto Bertollini of WHO-Europe apparently believes this:

“They simply have to be defeated,” Roberto Bertollini, the WHO’s representative to the EU, told a conference organized by the EU ombudsman on tobacco in late April.

It sounds as though WHO is at war with the tobacco industry.

Big Tobacco is winning

If this is the WHO’s war, then it isn’t going very well. The easiest illustration is with British American Tobacco’s share price since 2000 – it is the most international tobacco company that has been a single entity over the period of WHO’s heightened activity on tobacco, following the agreement of the Framework Convention on Tobacco Control in 2003.

If this is winning, what does losing look like?

If this is winning, what does losing look like?

BAT has grown by 545% since the FCTC was signed. For comparison, the FTSE 100, where BAT is listed, grew by 55% and the Dow Jones Industrial Average grew 106%. The combined market capitalisation of the six largest quoted companies (PMI, BAT, Altria, Japan Tobacco, Imperial and RAI/Lorillard) is now about $600 billion. And that doesn’t cover the biggest of them all – the Chinese National Tobacco Corporation, which has perhaps one-third of global cigarette volume.

The wrong war: the confusion of tobacco policy aims

Look again at the rhetoric surrounding WHO’s approach from the Politico article – this time including the context for Bertollini’s quote (emphasis added):

Smoking and related habits cause six million deaths each year, the agency says, so its mission is to reduce smoking by any fair means at its disposal. “They simply have to be defeated,” Roberto Bertollini, the WHO’s representative to the EU, told a conference organized by the EU ombudsman on tobacco in late April.

WHO wants to “reduce smoking by any fair means at its disposal“. But in the next breath, it assumes this means the tobacco industry “simply has to be defeated“.  As above, that isn’t going well, so maybe WHO needs to rethink its “war aims”.

Possible goals for tobacco control. This is why we have to be precise about goals. Is the overarching goal to:

  • reduce disease and premature death?
  • reduce smoking?
  • reduce tobacco use?
  • reduce nicotine use?
  • reduce uptake of cigarettes / tobacco / nicotine by teenagers?
  • reduce exposure to bystanders?
  • defeat the tobacco industry?

Think trade-off… The easy but lazy thing to say is “all of the above” and then to carry on doing counterproductive things without thinking. The reason that clarity about goals matters is that some of these goals conflict and there are trade-offs. You might push for one but do worse on another. For example:

  • It will be easier to reduce disease and smoking if you don’t insist on trying to eliminate nicotine as well – giving up smoking is one thing, giving up smoking and nicotine require more effort.
  • If you set targets to eliminate tobacco use you will lose the option to promote smokeless or heated tobacco products as an alternative to smoking, and more people may smoke as a result.
  • If you try to stop teenagers using vape products or smokeless tobacco, they might just smoke instead – and the efforts you make to ‘protect’ them from something much less dangerous than smoking might harm adult smokers.
  • You might find it easier to get smokers to quit smoking if you give them better ways to respond to your more traditionally coercive MPOWER measures.
  • You will help smokers switch to vaping if you don’t force vapers out of public places by law for no reason.
  • And you might do better trying to push cigarette companies to become smoke-free nicotine companies at the greatest possible rate of transition, rather than trying to “defeat” them, which has been a failure so far. If they start to drive the change of the nicotine market, it may proceed faster than if they are entrenched as cigarette companies.

Ban sex? No-one would find these contradictions difficult to understand if activists were convinced that the only way to tackle HIV was to campaign against having sex “because that is the only 100% safe option”. The risks would be immediately obvious: that people would continue to have sex (we’re mammals, that’s what we do), but they’d be doing that without the other ‘harm reduction’ options that would keep them safe, like condoms.

Big Tobacco is Rich Tobacco because…. The reason that the tobacco industry has not been ‘defeated’ is the same reason why alcohol prohibition didn’t work and the War on Drugs is a blood-soaked fiasco.  Billions of people like using the most widely available recreational drugs – caffeine, alcohol and nicotine – and many like drugs that have been arbitrarily deemed illicit.  Where there is a demand, there will be a supplier and a price that matches supply and demand. As we know from illicit drugs, outright prohibition, plain packaging, total ad-bans, punitive prices, uncertain product quality, and plenty of ‘reefer madness’ scare stories have failed to disrupt a vibrant criminal enterprise worth more than $400 billion per year.

The case for focussing on harm with a public health philosophy is far stronger than the case for prohibiting drugs with a criminal justice mentality.

Clarity about nicotine, smoking and disease – a thought experiment

In question 2 of my perpetual quiz on tobacco and nicotine, I try to tease out underlying objectives.

2. If you could choose between two theoretical outcomes for your community by 2020 what would you prefer:

The second option (b) has twice the nicotine use and half the smoking.

I would definitely choose (b) without any hesitation – even though it may increase the number of nicotine users and might even expand what are currently tobacco companies (neither being outcomes I want or welcome).  But this is because I am clear on the right goal: reducing disease and premature deaths, and I don’t really care that much if the amount of nicotine use increases, as long as it overall reduces the toll of disease while respecting people’s choices and without resorting to coercive or punitive policies.

PS. If you haven’t taken the quiz, please do!

Despite what is widely known of the risks, smoking is still very widespread and probably still rising as population and incomes grow.

Slide2

In fact, I would venture that the main reason that nicotine use has come down at all in the developed world is the deep conflation and confusion about the relatively benign drug itself (nicotine) and the serious harms arising from consuming it via tobacco smoke as the delivery system.  If it was available in forms that didn’t cause much harm, would more people use it?

The point is essentially economic: a great cost (the dread of cancer, emphysema and heart disease) has been added incorrectly to nicotine use per se. It is this dread cost and the costs to individuals of the policies ostensibly designed to reduce it (e.g. by denormalising smoking) that are driving people away from using nicotine.   It is not a sure sign of an inherently declining preference for nicotine itself. 

The conflation and confusion are evident in a chart in the May 2016 ASH Survey on vaping.

Attribution of harm to nicotine

Only “none or very small” is a correct answer – and only 14% of the at-risk group (current smokers – the left-hand group) get this right.

Signs of a misguided war on nicotine

Many groups claim their objective is tackling the burden of disease caused by tobacco. Good. The overarching World Health Assembly objectives in this field are expressed in term of reducing ‘non-communicable disease’ by 25% by 2025.  Their stated “war aim” is the reduction of disease and WHO’s tobacco objectives are there to contribute to that. However, I think their behaviour and rhetoric reveal a different and unstated objective – nicotine prohibition.  This is evident in so many ways:

  • The worldwide public health assault on vaping. It is as though there is a terror in public health that people might use nicotine without the death aspects of smoking to restrain them and make it feel like a deviant behaviour.  But that terror is driven by nicotine prohibitionism, not a concern about disease. Dr Chan has even recommended that that national governments ban e-cigarettes.
  • The ban on snus in the EU and the persistently misleading commentary about its health impacts in the tobacco control community.  Snus in Sweden is the source of one of the greatest public health victories in Europe, as seen in Sweden, yet the extent of denial, including by WHO, about this unassailable reality is extraordinary and shocking.
  • The FDA/NIH programme on reducing nicotine in cigarettes to ‘sub-addictive’ levels, which involve forcing people to quit smoking, but with ambiguity and weasel words about what they should do instead. Why wouldn’t they reduce the ratio of harmful agents to the relatively benign drug?
  • The effort to ‘defeat’ the tobacco industry – only nicotine prohibitionists would not want them to become nicotine businesses rather than cigarette businesses, and as rapidly as possible.

If you wage war on nicotine rather than on disease, is it any surprise that you end up with this confusion and closing down one of the most promising and consensual options for quitting smoking and reducing disease? The war on nicotine is a war on harm reduction and a driver of harm. It is no different to fighting a war on sex and insisting on abstinence in order to control HIV or teenage pregnancy – condoms are a better idea.

The nicotine prohibitionists risk finding themselves on the wrong side of some major trends in society.

  1. Society’s attitude to substance use is undergoing a transformation. We are becoming less judgmental about substance use and more concerned about harm to users and others – including collateral damage caused by policies designed to control substance use. We are becoming increasingly sceptical about prohibitions, such as that tried with alcohol and the ‘war on drugs’, and we are seeing states liberalising cannabis laws.
  2. Nicotine is widely used and legal, and that is unlikely to change, either by prohibition or by choice – and it would be undesirable and unethical to try. The internet trade in nicotine liquids will be virtually impossible to contain and over-zealous regulators will find themselves flat-footed as consumers and international businesses combine to design new supply options.
  3. Society’s attitude to nicotine is undergoing a transformation – the deep conflation between nicotine and smoking is breaking apart. Because of vaping and long-running natural experiments such as snus in Sweden, we are increasingly confident that nicotine can be consumed with little or minimal harm. If we separate the nicotine and smoke we no longer have most of the harms associated with using nicotine. In a situation where there are not mortal risks or harm to others, it is possible more people will wish to use nicotine, or it is possible that nicotine use will decline too. We should be less concerned about the number of nicotine users and focus on the number of long-term smokers.
  4. The technology in nicotine use is undergoing a transformation. After little change over many decades, the primary nicotine delivery system is changing. The key to this has been an energy technology – the battery – which now has energy and power density to heat enough vapour fast enough to create an aerosol that can deliver a satisfying nicotine experience in a small size with an acceptable battery life. The energy source in cigarettes, combustion of tobacco, has been both part of the experience and created most of the problem.
  5. Tobacco companies will undergo a transformation from a cigarette businesses to a nicotine businesses, and from combustion products to non-combustible products. To the extent they fail to do this they will be defeated – not by WHO, but in the long run by the preferences of consumers and pace and innovation of competitors.
  6. Regulators can either facilitate these transformative processes or inhibit them. To the extent they try to inhibit them they will be pushing against major shifts in society’s attitude to drugs and will do more harm to health and welfare.

9 comments to Who or what is the World Health Organisation at war with?

  • […] [1] Bates C. Who or what is the World Health Organisation at war with? The Counterfactual, May 2016 [link]. […]

  • Sue Wilson

    IF it’s a war on nicotine (which I assume it is as WHO is anti-vaping), then it stands to reason that they should also be anti-NRT. The only difference between vaping and NRT is that vaping kit is produced by independents and tobacco companies whereas pharma produce NRT, and WHO wouldn’t be trying to protect the market for pharma, would it?

    The policy is confused. This has led to the public being confused. The result is that many smokers have been frightened away from a much safer way of continuing their recreational nicotine use.

    The part of this fiasco that really makes me sick is that the individuals at WHO (and spokesmen for the BMA, and a couple of maverick public health bods, who are equally misinformed about vaping) will not be censored in any way for the excess morbidity and mortality that their biased views will cause. These individuals have, or should have, the skills to read the body of existing research in a critical and objective fashion; to cherry pick from the literature is not only unprofessional, but, in my opinion, criminal. I don’t know how they can sleep at nights.

  • […] sock-puppet charities have done little to curb the demand – in fact, as Clive Bates points out here, the sustained “war” has had the complete opposite effect on the tobacco industry, […]

  • […] EU wide, the number of new smokers vs former smokers remains fairly balanced despite the “war on tobacco” – a war that has only really got one casualty – the average, everyday […]

  • […] The World Health Organisation does a good line in war-like rhetoric when it comes to tobacco policy. But what is it actually at war with? In this post, I examine the confusion in ‘tobacco con…  […]

  • My understanding is that unlike the U.S., other countries have signed treaties with the WHO which involve donation of funds as well as obedience to WHO goals and directives.

    I also understand that WHO has a very legitimate desire to do a lot with vaccination, and probably depends not only on contributions, but also discounts and goodwill, from the pharmaceutical companies.

    So I have a couple of questions.

    Can treaties be broken based upon WHO’s failure to do their job wrt combustion and smoking, i.e. they are causing harm, which I presume isn’t in the treaty as an allowable behavior?

    If countries that now contribute to WHO were to switch their international medical donations to Doctors Without Borders instead, would the result be roughly the same level of care for the people of poor countries?

    Just wondered.

  • Bob Pearson

    I understand that along with the Bill Gates foundation, Big Pharma makes a significant contribution to WHO. If vaping or Snus becomes really mainstream & lit tobacco becomes a thing of the past, then certain cancers,COPD, Cardio Vascular disease & many other illnesses will diminish. A great Public Health win for the world. However, there is a symbiosis between the Tobacco Industry and the Pharma companies when it comes to tobacco. Tobacco makes us sick, Pharma treats us with expensive & profitable drugs, win win. What’s the incentive for either of those industries to radically change whilst huge profits can be made from making people sick.

    Imagine for a moment, remember Star Trek & Dr McCoy’s magic little box that chirped? It could diagnose & cure everything with a wave. If someone invented that now, the end to all disease, the WHO would, along with Public Health, try to get it banned. No profit in ending disease, much more money in treating it.

  • Roger Hall

    Alternatively their objective is simply rhetoric and the illusion of fighting tobacco as long as the measures adopted fail. Let’s face it surely anyone with an iota of intelligence can look at the statistics from Sweden in terms of smoking prevalence and smoking diseases and clearly see that banning snus has been counter productive to Public Health. Even after decades of long term use and studies has the WHO promoted Sweden’s model? Everyone talks about Big Tobacco, yet surely the other significant beneficiary of the harm from tobacco is Big P. There may well be an illusion of a war against tobacco, but who are the real allies of WHO? Whose lobbying actually influenced the EU to include e-cigs within the TPD in order that they be treated the same way as snus? Lord Callanan’s recent speech in the House of Lords answers many a question.

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