Today sees a new e-cigarettes assessment from England’s public health authority, Public Health England. It includes an excellent evidence review by Professors Ann McNeill and Peter Hajek and their colleagues. Great kudos must go to Kevin Fenton, Rosanna O’Connor, Martin Dockrell and their colleague at PHE who have been determined to get this issue right – to maximise the benefits and to take an evidence-based approach to managing the risks.
The package is here: E-cigarettes: an evidence update comprising:
- Report: E-cigarettes: an evidence update (111 pages)
- Policy document: E-cigarettes: a new foundation for evidence-based policy and practice – 6 pages
- Press release: E-cigarettes around 95% less harmful than tobacco estimates landmark review
- Authors’ note: Underpinning evidence for the estimate that e-cigarette use is around 95% safer than smoking
It has had great media traction in the UK (Google news) though with perhaps too much emphasis on whether the National Health Service should pay for e-cigarettes – something that would be only permitted when medically licensed products become available (see comment on this below). But the overall endorsement of vaping as a harm reduction strategy for public health is strong and compelling. Also see the statement of the New Nicotine Alliance:
Key messages – from the short briefing on implications for policy and practice….
E-cigarettes: a new foundation for evidence-based policy and practice
Safety and the perception of risks
It is important that the public be provided with balanced information on the risks of e-cigarettes, so that smokers understand the potential benefits of switching and so non-smokers understand the risks that taking up e-cigarettes might entail:
- when used as intended, e-cigarettes pose no risk of nicotine poisoning to users, but e-liquids should be in ‘childproof’ packaging. The accuracy of nicotine content labelling currently raises no major concerns
- the conclusion of Professor John Britton’s 2014 review for PHE, that while vaping may not be 100% safe, most of the chemicals causing smoking-related disease are absent and the chemicals present pose limited danger, remains valid. The current best estimate is that e-cigarette use is around 95% less harmful to health than smoking
- e-cigarettes release negligible levels of nicotine into ambient air with no identified health risks to bystanders
- over the last year, there has been an overall shift among adults and youth towards the inaccurate perception of e-cigarettes as at least as harmful as cigarettes
Implications of the evidence for policy and practice
Based on the findings of the evidence review PHE also advises that:
- e-cigarettes have the potential to help smokers quit smoking, and the evidence indicates they carry a fraction of the risk of smoking cigarettes but are not risk free
- e-cigarettes potentially offer a wide reach, low-cost intervention to reduce smoking in more deprived groups in society where smoking is elevated, and we want to see this potential fully realised
- there is an opportunity for e-cigarettes to help tackle the high smoking rates among people with mental health problems, particularly in the context of creating smokefree mental health units
- the potential of e-cigarettes to help improve public health depends on the extent to which they can act as a route out of smoking for the country’s eight million tobacco users, without providing a route into smoking for children and non-smokers. Appropriate and proportionate regulation is essential if this goal is to be achieved.
- local stop smoking services provide smokers with the best chance of quitting successfully and we want to see them engaging actively with smokers who want to quit with the help of e-cigarettes
- we want to see all health and social care professionals providing accurate advice on the relative risks of smoking and e-cigarette use, and providing effective referral routes into stop smoking services
- the best thing smokers can do for their health is to quit smoking completely and to quit for good. PHE is committed to ensure that smokers have a range of evidence-based, effective tools to help them to quit. We encourage smokers who want to use e-cigarettes as an aid to quit smoking to seek the support of local stop smoking services
- given the potential benefits as quitting aids, PHE looks forward to the arrival on the market of a choice of medicinally regulated products that can be made available to smokers by the NHS on prescription. This will provide assurance on the safety, quality and effectiveness to consumers who want to use these products as quitting aids
- the latest evidence will be considered in the development of the next Tobacco Control Plan for England with a view to maximising the potential of e-cigarettes as a route out of smoking and minimising the risk of their acting as a route into smoking.
Please comment and share your views!
Some observations from me…
On the 95% risk reduction… this should be seen as a worst case and cautious claim based on current knowledge. There is currently no identified serious health risk associated with vaping, so it is best to see the residual 5% risk as an allowance for uncertainty. The claim for a 95% risk reduction is necessarily an expert judgement on the part of the authors mediated by PHE. Their reason for optimism is down to what is known of the chemical constituents of e-cigarette vapour. Most of the constituents of cigarette smoke that are thought to cause harm are either not present in vapour or present at levels well below one twentieth of that in cigarette smoke. The physical basis for the claim is multiple studies of vapour toxicity compared to what is known about cigarette smoke. Notably the following:
- Burstyn I. Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks, BMC Public Health 2014;14:18. doi:10.1186/1471-2458-14-18 [Link]
- Farsalinos KE, Polosa R. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review. Ther Adv Drug Saf 2014;5:67–86. [Link ]
- Hajek P, Etter J-F, Benowitz N, Eissenberg T, McRobbie H. Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction. 2014 Aug 31 [link]
On naming a number. Quantification was used because that has more impact and more directly gets to the right ball park (i.e. “much less than” could mean 50% or 70% less, which would hugely overstate the risk), and therefore more people will have better aligned risk perceptions as a result. It is a way of saying “a lot less risky, but you can’t be sure they are entirely safe” but getting closer to what the scienec actually says. It is grounded in a cautious view of toxic exposure but it would have been difficult for this public body to say 99% less or 100% safe with confidence – I’d see the 5% residual risk as a ‘safety cushion’.
On claims that are true but still wrong (or not right enough). This claim should be seen as competing with hundreds of other risk-related claims that mostly deliberately mislead or, though well meaning, understate the risk differentials. For example the proposed claim for snus submitted to FDA, “No tobacco product is safe, but this product presents substantially lower risks to health than cigarettes”, could mean 20%, 50%, 70% or 98% lower. But only the last of these is approximately right. So the claim does not convey the two orders of magnitude of the risk reduction (>98%) that would be a reasonable estimate for snus compared to smoking. So this claim is in the category ‘true but incomplete and misleading’. Even so, I am supporting the snus claim as being much better than the FDA default (“this product is not a safe alternative to smoking”, which conveys no useful information. So in a world of imperfect claims and incomplete caveats, we should give kudos to claims that shift perceptions closer to reality, are simple and blunt enough to have impact and provide a better basis for informed choice. The PHE claim does that.
On the corrective to inaccurate risk perception… I think the 95% claim is best understood as a risk communication designed to better align risk perceptions with reality. PHE and many others have been increasingly concerned that the perception of e-cigarette risk compared to smoking is way out of line with reality, and seems to be getting more out of line as the evidence of relative safety strengthens – many scare stories and baseless moral panics have contributed to this, and may be having the effect of putting smokers off trying e-cigarettes and so continuing to smoke. The 2015 ASH Smokefree GB adult survey showed only 52% thought they were less harmful – but even this group don’t necessarily have accurate perceptions of how much less harmful – even half or two thirds less harmful is a huge over-estimate of risk. A responsible public health body tries to align public risk perception with actual risk to the extent possible – and this is the point of PHE making a bold simple-to-understand claim about the relative risk. The alternative is to let smokers form their own perceptions from news stories and media academics determined to demonise the products – all the evidence suggest this approach leads people to greatly overstate risks or understate the risk reduction. A responsible public body does its best to give people a realistic and understandable anchor for making behavioural choices. A good working assumption is that vaping is not entirely safe, likely to be 95% less risky than smoking, but may ultimately prove to have no mortal risks. It should help to do the right thing, which is contribute to consumers making better informed reality-based choices – which is what PHE is trying to do, but CDC isn’t.
What if the 95% claim is wrong? There is a risk that the claim is wrong – most likely that the claim is over cautious and that the implied residual risk of 5% it is too high, but it is also possible that some unknown unknown will render it too low – though I doubt that for a range of reasons. The usual way public bodies approach this risk of being wrong is to say nothing, to fudge and hedge, or to allow smokers to form their own perceptions from the maelstrom of ill-informed and malicious comment that circulates in this field. The result as we know is that consumers greatly overstate the risks of these products – many believing there is no difference in risk between cigarettes and e-cigarettes, and few appreciating the magnitude of the risk reduction. This caution transfers misperception risk from the public body to the consumer and is basically irresponsible. In the case of CDC and California Health Dept, it is worse than irresponsible – as they are purposefully trying to exaggerate the risk. In comparison, PHE is being responsible and proactive in making this claim: PHE is taking a risk of being wrong in order to help consumers be much more likely to be right.
Does 95% still mean thousands die? The UK premature death toll from smoking is about 100,000 per year (see CTSU for other countries). This claim isn’t really designed for the arithmetic of body counts. The residual 5% is really just a safety factor that allows for unknown effects and reflects the caution of bureaucrats and a concern not to imply they think e-cigarettes are safe. But what if it is taken literally? One other way to address this is to ask what does the 100,000 UK smoking-related deaths mean anyway? In reality, smoking causes a shift in the life-expectancy curve… you can see this in the seminal Doll & Peto doctors’ study: see key image here (reproduced below) and the full paper here.
You could use this curve to characterise the smoking risk as follows (based on the arrow on the graph): the median smoker loses 10 years of life between the age of 73 and 83.
So if it actually was 5% of the risk, these curves would become much closer. Then you might think of this as: the median vaper loses 6 months of life between the age of 82.5 and 83.
I think is a better (less alarmist) way of putting it than just saying 5% x 100,000 will die. But I think the best approach is not to get too arithmetical about this – as I say, if the 95% has any basis it’s an upper limit based on expert assessment of toxic exposure. So the PHE position is designed to convey long-term health risks that are about two orders of magnitude lower in a way people can understand, not to provide a precise basis for making a body count.
On risks to bystanders… the review follows all the main assessments to date and shows no material risks to bystanders from airborne nicotine or other vapour constituents. Risk to bystanders would normally be the justification for laws to control vaping in public places. But in the absence of risk the issue become one of etiquette for vapers, choice for owners and managers of premises to create the atmosphere and clientele they want, and consideration of the wider health implications of allowing or not allowing vaping in a particular public place. For example does allowing vaping encourage smokers to switch, does banning it encourage vapers to relapse? The government in England is right to think this way and has no plans to use the force of law to ban vaping. On the other hand, the Welsh Government’s proposal to use the law to ban vaping in all public places is an excessive authoritarian intervention that lacks an ethical basis and will do more harm to health than good.
On medicalisation of vaping… the vaping phenomenon is best understood as a market-based transformation of the recreational nicotine market in a way that is good for health – hopefully leading to a substantial shift away from smoking and into vaping. It should be seen as a mass-market alternative to smoking rather than as a treatment for a condition in which a smoker presents to a public health agency with a harm-causing addictive condition seeking a cure. That may sound pedantic, but getting the policy framework right will depend on policy-makers having a realistic grasp of how the benefits come about. That is not to say that NHS, GPs, Stop Smoking Services and public health organisations should ignore them – just that they shouldn’t see it as another form of NRT or Champix. If they want to advise smokers on these products they will need to compete with the expertise available on dozens of forums and be credible experts with smokers. Most of the public sector is way behind the curve on this.
On the shift away from ‘if all else fails’… much of the public sector discussion of e-cigarettes as alternatives to smoking has tended to see them as a last resort to be tried if all other options have failed. This new package appears to provide a welcome change from that – stressing the interests of smokers in finding options that work for them. Also, it’s difficult for the public sector to maintain the ‘if all else fails’ approach while they are providing charts showing high levels of comparative success among those choosing vaping products – as below.
Support used and stop smoking service self-reported quit rates
On the Stop Smoking Services… as you might expect from a public sector public health body, PHE places a lot of emphasis on what role the public sector plays – i.e. through Stop Smoking Services. It is often claimed that the best results come from behavioural support combined with pharmacotherapy of some sort. That might be true, but it addresses a particular subset of smokers – those willing to go to services and complete a behavioural course. Many of the Stop Smoking Services have let themselves down by going into opposition against this bottom-up approach to quitting smoking, but that is now starting to change, with pioneering work in Leicester and the North East and many others adapting to the real world. For me the key role of the public sector is to provide truthful reliable information to those who want it, and encouragement to try this approach to quitting – whether a government web site, a local authority public health programme, a GP surgery or a dedicated Stop Smoking Service. The PHE evidence reports are probably the most important thing the public sector does, because they affect the behaviour of all other actors.
On prescribing e-cigarettes… much of the press coverage picked up on the idea of prescribing e-cigarettes (i.e. making the available free via smoking cessation services). I think this should be downplayed and the normal expectation should be that people will buy e-cigarettes with their own money and from savings made in quitting or reducing smoking. The excise regime should support that. We need to see this a market-based solution (like snus in Scandinavia) and work on the basis that markets will provide the necessary innovation and affordable quality products if not over-regulated. It is not necessary for every problem in society to be addressed with public sector interventions and public spending. As Sir Jeremy Heywood, the UK’s most senior civil servant, puts it in his blog on e-cigarettes:
It’s easy to think that the solution to a policy problem is to fund a new programme or put in place new legislation. These are, of course, important parts of a policymaker’s toolkit, but new approaches can often help us to solve the problems that we face.
Where I have been persuaded (by Linda Bauld and Deborah Arnott) that some intervention is justified is in helping the poorest smokers to get started on vaping. If you are a smoker on a very tight weekly budget, then the economics of a switch to vaping can look daunting – there are upfront startup costs to get to the better tank/mod products (which are then much cheaper overall) and you might be concerned that you’ll try e-cigarettes, they won’t work and you’ll have to buy the cigarettes as well. So for health inequalities reasons there may be a case to assist low-income smokers in making a transition. But for me, that’s all. It shouldn’t be a routine call on the public purse. It’s good to have health interventions where no taxpayers are harmed.
On medically licensed e-cigarettes… I think that the distinction between licensed and unlicensed nicotine products is unhelpful and a distraction in policy terms. The medicines regulatory regime is so burdensome, restrictive and expensive that it cannot be assumed that the products that pass through it will be better for smokers – they are more likely to be designed to meet regulatory requirements than to meet actual smokers’ needs. The example of NRT should serve as a warning: ‘licensed’ doesn’t mean ‘better’. The Tobacco Products Directive is useless, but the logical approach would be to allow any products that are compliant with that regime to be used in publicly funded programmes. In the post-TPD world, medicines licensing may have some advantages to the bigger tobacco-owned vendors who can bear the compliance costs – lower tax, advertising allowed, more proportionate warnings etc. But these advantages arise primarily from the failure of the TPD to provide a sensible regulatory regime for e-cigarettes rather than any safety, quality or efficacy benefits to the consumer.
On the Tobacco Products Directive Article 20 – this is a truly dreadful piece of legislation, made in haste on the foundations of bad science, bad economics, bad ethics and bad process. If this evidence review had been available during the negotiations we might have better legislation – but instead of taking care to get this right and save thousands of European lives, the European legislature just blundered on full of hubris and anti-scientific delusions. The directive was based on junk science from WHO (here and here) and negligence on the part of the European Parliament rapporteur (here), evidence free ideas of the European Commission (here) and the unrivalled pomposity and negligence of the European Council and its Irish presidency along with many other actors (here). I really do hope lessons are learned.
On the messages for others… Public Health England has done what a good public health body should do – looked at the evidence, thought about its responsibilities and worked through how to bring evidence into policy and practice. How many of its peers in other countries can claim the same? Where is the equivalent analysis from CDC or the extremists in California? What do Australia and Canada have to back their prohibitionist positions? When will WHO start to act as though e-cigarettes are part of the solution, not part of the problem? What messages will Gates, Bloomberg and Soros take from this? Why does CTFK decline to do what the much more modestly funded ASH does in the UK? Where are the open minds in cancer, heart and respiratory charities and societies? The message for others is simple: stop believing the rhetoric of prohibitionist activists and anti-corporate campaigners and take a cool hard look at what is really going on and what the evidence tells you – then act accordingly.
Its good that finally a detailed, evidence based document has been released.
Some in the ban it all brigade must be having panic attacks over the truth being released so openly.
Maybe finally the adults can have sensible debate about this rather than letting the “kids” shouting distract from it.
Of course the soon to arrive TPD implementation is going to destroy many of the gains made and that really needs sorted out but at least this is a start.
I agree the media is making too much of the NHS angle, we know after all millions of people have managed to find and use e cigs without them being handed out free. Also we know the medically approved devices are likely to be unappealing to the majority anyway.
STOP TPD!!!
SIGN AND SHARE!!!!
https://petition.parliament.uk/petitions/105139
I think suggesting they should be prescribed on the NHS damages the vapers’ cause and probably isn’t welcomed by most vapers. It gives the Authorities an excuse for interfering in a legal and harmless activity. It also understandably alienates the public, still groggy from being punched by the gluten-free food on the NHS revelation. What next? Bingo on the NHS? Why was that suggestion made? Smoking even smuggled cigs costs £25 a week.Smoking legally costs over £60 a week. Vaping costs at most £6 a week for refillable devices.
Jonathan – I agree… I think this is mostly a distraction, expect perhaps for getting the very poorest smokers started.
I agree, the idea of adding a potentially unknown cost- after all ecigs are not a medical treatment for a known disease, some people might be getting their ‘prescriptions’ for decades – would give treasury types the conniptions. A limited needs tested subsidy for ‘startup packs’ might be better.
Further to my comment: a great deal of the enormous (which is good) ensuing discussion in comment sections has concerned the NHS prescription aspect of the report; and has diverted the discussion away from possible health risks and the EU TPD.
I agree that the NHS prescription route is – in the main – unnecessary. And that only very large companies – such as the tobacco companies – are probably the only ones that will be able to afford the cost of producing medically approved devices and liquids. I hope the politicians will be very careful about going down that route. But even more I hope they will read, digest and act in accordance with the PHE report, and not just dismiss it because it disagrees with the stupid WHO advice.
I do wish that our media would be more responsible in reporting on such matters. The prescriptions for gluten-free food is another case in point. I am not coeliac but have a mild allergy to gluten that causes my legs and gut to swell up when I eat it. Luckily I am not poor, so can afford to buy gluten free alternatives to bread, pasta, biscuits, etc. You would not eat these if you did not have to – the lack of chewiness makes them quite unpleasant. AND they are very much more expensive than the gluten-containing, tastier alternatives. But the public, led by the nose by the media, seem to think that anyone – including people struggling on benefits – should just pay the cost of this illness themselves. Yet they accept that diabetics should get free prescriptions for everything – even headaches! Where is the responsible reporting that this country needs so badly, to make the arguments clear, accurate and accessible to the average person. I’m sure the media used to be much better at this when I was young – before the advent of the sensationalist papers that make people such as Murdoch rich and leave the public over-informed about the lives of the famous and under-informed about anything of real importance!
Thank goodness for sites like this one on the internet. But sadly not enough people seem to read them.
Great piece of work by PHE and great piece of analysis by you. I agree that the proposition to fund through the NHS is a rather unnecessary attempt by health professionals to get their mitts on something – rather than leaving well alone (though see your case for upfront support for poorest). but I thought some of the most interesting stuff in the report was its conclusion that the current non-regulatory regime had actually worked well in supporting the growth of the market – making obvious the threat from bad TPD style regulation. and the fact that a lot of those who tried didn’t stay with vaping suggests the real public health wins need a regime which fosters more rapid innovation to develop better products (including products which can meet the needs of the most nicotine dependent). But PHE showing the way in evidence-based policy making!!
Jill – you make a very good point… what exactly is the problem that the TPD regulation is supposed to address? Would anyone be worse off if it simply wasn’t applied? All i see is a brake on the pace of innovation and market diversity that is serving the public and public health so well at present. The TPD is useless as a single market measure – but it carries the added risk of reversing progress that has been made in harm reduction under light-touch consumer regulation.
For methe nature of this milestone is in pushing the burden of proof into the anti camp for the first time.
The domino effect has started, let’s hope it’s international in scope.
Hear, hear!! I second that!
Oh, excellent news! Quote – “the logical approach would be to allow any products that are compliant with that regime to be used in publicly funded programmes.” Probably a waste of tax payer money as they might put poor people off vaping for life! :-D
Lovely, uplifting post, thank you.
Article 20 could screw it all up…
True – but it would cover all products legitimately on the market. It would be a stretch to have the government offer black market products.
I think PHE have explained the 5% risk calculation really well in the interviews I have caught today, but one interpretation of that figure could be that for 100,000 annual UK deaths from smoking, there would be 5000 deaths from ecigs. Of course even if ecigs did carry this risk, they would take decades to come through the pipeline, but it could still be construed that way.
I would love to see ecigs promotion where is exists as leading with the factual statement that it does not contain tar. No reason why they could not under the current ASA guidelines.
Andy – that’s precisely the danger with this sort of number, and why they should be clear that is an ‘at least’ 95% reduction – it is possible that these products will cause no measurable long term mortality loss, and any problems may be manifest as minor ailments like chest irritation. The residual 5% is really just a safety factor that allows for unknown effects. The 95% number is derived from estimates of toxic exposure – most of the harmful constituents of cigarette smoke are either not present in e-cigarette vapour or present at level at least 20x lower, often very much lower than that (e.g. 1000x lower for nitrosamines).
One other way to address this is to ask what does the 100,000 UK smoking-related deaths mean? Actually, that is in itself a communication device. In reality, smoking causes a shift in the life-expectancy curve for smokers… You can see this in the seminal Doll & Peto doctors’ study: see key image here and the full paper here.
You could use this curve to characterise the smoking risk as follows based on the arrow on the graph: the median smoker loses 10 years of life between the age of 73 and 83.
So for 5% of the risk, it might become: the median vaper loses 6 months of life between the age of 82.5 and 83. That is a better way of putting it than just saying 5% x 100,000 will die.
But I think the best approach is not to get too arithmetical about this – as I say, it’s an upper limit based on expert assessment of toxic exposure. So the PHE position is designed to convey long-term health risks that are two orders of magnitude lower in a way people can understand, not to provide a precise basis for making a body count. It is designed as a corrective for smokers who don’t even think the risks are lower at all, or who think they might be as much as one half or one third at risk. It’s trying to get people in the right ballpark, without giving a reassurance that they are risk-free. To me this is what a responsible public health authority does – tries to get realistic alignment of public risk perceptions with scientifically plausible assessment of risk.
Clive my understanding is that “smoking related” does not necessarily mean smoking caused (or even a strong association) rather it is simply a ‘association’.
For example if somebody smoked, socially, for 10 years between 1955 and 1965,and then completely stooped smoking. And went on to be by 2001 very obese, had type2 diabetes and then in 2014 had died of heart disease and other type2 related health issues. That death would be statistically (separately) counted as a obesity related death and as also a “smoking related” death. I.e that person would have for the purposes of the statistics ‘died twice’.
My understanding was that it was even more tenuous than that. Let’s say that, despite absolutely no proof whatsoever, PH decide that smoking is now a cause of scurvy. Therefore, even if you have never seen any tobacco related produce in your life, if you die of scurvy your death can now be attributed to a smoking related disease and used to distort statistics.
As an Australian I’m hoping that this news may help us to convince our various state and federal governments to regulate with a much much lighter touch so smokers can have the opportunity to see if vaping works for them. The NHS funding it though worries me. Vaping works because its consumer driven and companies adapt to peoples needs quickly. I can’t see that happening with anything that’s been through something as arduous as getting medical approval.
Hopefully it will be useful in NSW; the Liberal (conservative) governments bill which would only prohibit supply of egigs to minors(i.e prohibit nothing else) is currently ‘hanging’ in the upper-house where the government is one vote short of a outright majority. There are a number of crossbenchers , only need to convince one…
You really wonder if the antis have gone in so deep that they cannot back out. I’ll be interested in their calculated reactions. Either way its great that this has happened *at the very least* to reverse the harm done by misinformation that is stopping a potential smoker from giving it a go (if they want to) or even worse for those that have gone back to smoking from vaping due to these scare stories.
A great kick up the proverbial for Australia bound by the death grip of the Anti-tobacco harm reduction cabal (you know who they are).
Just an aside on the “Support used and stop smoking service self-reported quit rates” and the comparative position of ecigs.The SSS use the 4 week rate because it’s easy – and I suspect the high number shows them in a best possible light.
In reality following the standard abstinence relapse curve reduces the success rate to ~15% at 3 months and ~8% at 12 months.In theory (and almost certainly in practice though the figures aren’t reported) the relapse curve for THR should be different – if a quitter has the desire and finds a suitable device there is no reason to relapse.
It may not lead to abstinence of everything but an acceptable alternative means abstinence from lit tobacco which is all we seek.
Sure, all first baby steps should be encouraged, but TC still do not realize that this “you will be assimilated into the hive of smoke-haters, resistance is futile” mentality is not doing it for all the Jean-Luc Piccard’s out there, who make up their own well informed minds, who have been able for decades to distinguish between real and junk science about smoking, and still have the same capacity to do so when it concerns vaping. Honestly vapers didn’t develop this capacity overnight the day they switched from smoking to vaping. TC still are not getting it what this is really about, don’t they. You nailed it Clive: “A responsible public health body tries to align public risk perception with actual risk” It goes without saying in order for people to be able to make well informed decisions based on an accurate risk-reduction assessment this should not only apply to vaping but also to smoking. A truly responsible public health would also try to align the perception of risk of smoking with the actual risk not only to the smoker himself but also the actual risk to the bystanders of second hand, third hand, fourth hand, fifth and sixth hand smoke and this in enclosed spaces as well as in open air,… all without any exaggerations, without wanting to create an hysterical panic, without the use of junk science or scare stories. Since we’re talking about risk-reduction as opposed to absolute risk, one can try as much as he wants to correct the inaccurate risk perception of vaping; without any trustworthy information on both smoking and vaping no-one is capable to assess or perceive the risk-reduction or relative risk accurately. But with smoking we have noticed for decades the complete opposite of what a responsable public health should do and with vaping we have witnessed the exact same thing for almost a decade now. There is some change in the latter but it is obvious that comparing the actual risk in all fairness of vaping to the totally made-up junk on smoking is totally meaningless and perceived intellectually unfair, especially to the smokers one is trying to convince of risk-reduction. This way the public health bodies in charge are planning (again) to have their usual success-rate of no more then 8% after 12 months. Comparing with obvious junk is not very convincing, not even to a hardcore vaper as myself, so how does one which to convince a smoker? And Art20 of the TPD is not the only ‘truly dreadful piece of legislation’ as the result of a totally irresponsible public health. We witnessed this week a small step for man, but still a very long way to go before it becomes a giant leap for mankind, meaning having that truly responsible health body we lost decades ago.
Many many thanks to you Clive for helping to convince PHE to do the right thing.
This is especially gratifying after JAMA falsely insinuated to doctors and the news media that e-cigs are gateways to cigarette smoking (by publishing a junk study that was never intended to assess potential gateway effects, but rather was designed to confuse, scare and lobby for FDA’s proposed e-cig ban and vaping bans.
A great step forward but disappointing to see them referring to “medicinally regulated products”,it seems that without an appropriate cubby-hole PH are lost.We know e-cigs are not medical products and are certainly not tobacco products so why cannot they be officially classified as what they are,Nicotine Containing Consumer Devices.Is this so hard?
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Excellent news and a great summary. The key question now should be how does this excellent report actually impact on the reality that is the TPD and Article 20? To date within the UK 1.1 million ex smokers have now totally given up smoking by adopting vaping over the past 5 years. Over a million more have reduced their tobacco use. Adult smoking prevalence at its lowest having now breached the previously static 20% rate. Compare this with the UK’s own Impact Assessment on the implications of the TPD where it projects that the TPD as a whole will produce just 200,000 fewer UK smokers between 2016 – 2020. The PHE report and its conclusions surely demonstrate that Article 20 is not fit for purpose, as in reality without Article 20 e-cigs have already historically generated 5 times the expected non smokers of a fully implemented TPD. From a public health perspective surely this demonstrates that Article 20 can’t be beneficial or even needed, but is more likely to reverse the massive impact that e-cigs have had over the past 5 years. So whilst it is excellent news that the PHE have released this report, it will only have real value if it is the catalyst that manages to abort Article 20. It will also be interesting to see how the Government and Dept of Health react to this in relation to the reality of Article 20 and whether they add their support for seeing Article 20 removed from the TPD.
Roger – you highlight the great frustration here. Very poor European legislation was made on the basis of an wholly inadequate grasp of the science, opportunities and risks by bungling political amateurs who were more concerned about getting an agreement than what the agreement says. However, I cannot see DH or the other member states back-tracking on the directive now – or supporting TW’s case. The only thing we can hope is that they will use their discretion to retain as much commercial freedom as possible, limit the restrictions and burdens and take a proportionate approach to enforcement. Or that TW scores a knock-out in court.
Clive – perhaps you could take this opportunity to explain to political laymen, such as myself, precisely what leeway a Government has with regard to the TPD. On one extreme, it could instruct all law breaking to be ignored and on the other, could enforce to the letter every clause. What is our Government likely to do? Are there examples of other countries effectively ignoring directives? Are they punished, and if so, how?
The directive cannot be changed now – it is literally a directive from the European legislature to the UK parliament or devolved administrations to introduce domestic laws that implement the TPD. The main feature of the TPD are not therefore under discussion. Directives don’t alway use actual legal text, contain, penalties or enforcement etc. So the domestic legislature has several tasks:
1. Transcribing the directive – including dealing with ambiguities in the TPD text
2. Adding all the stuff to do with compliance, enforcement, penalties,
3. Making choices where these are left to the member states – eg. if there are options to go beyond the directive, or choices of which institution does what (eg. deciding the competent authority)
The annoying thing about the DH consultation on TPD is that hardly any of the substance is up for discussion, as these things were settled in the directive, for which there has never been any consultation. It’s insulting frankly.
Clive in a general sense does the EU not have a way of withdrawing or majorly amending directives that are clearly a mistake?
Yes it does – but it is the same process as used for agreeing a directive in the first place (the Ordinary Legislative Procedure). The things that can be amended more easily are delegated acts within the directive – these relate to the reporting requirements and refill mechanism. Neither is finalised yet.
Clive , thank you for all your work!
By delegated acts, do mean the way the directive is interpreted into actual regulations ( am thinking of an analogy with epigenesis).
Or is it something else?
Delegated acts are bits of the directive where the legislature says to the Commission: “please fill in the technical detail later” (see explanation here. In TPD article 20 (on e-cigs) delegated acts apply to the data disclosure requirements and design specs for the refill mechanism.
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I belong to a Health Forum and many on there have severe resp disease along with a hatful of other nasties; I have been preaching the gospel on there for some time – why should they have to “quit or die” when they have problems enough? There were many posts welcoming the PH stance – there might have been a few more had it been made earlier.They are not really clued up on the details so below is the post I made today.
“This is a great outcome for those of us who have been into advocacy since 2012; it was a hard climb because most people, especially MEPs, knew nothing about e-cigs. The one thing we fought was the medicalisation of a product which was simply a smoking alternative – the European Parliament agreed and chucked it out. Then it went to trilogue wwhich is basically some unelected commissioners having the last word; they decided that anything over a certain strength would become “medical” and thus a money-maker for the Phatmaceuticals (who are dedicated and very rich lobbyists!) So we have a two-tier system. I, like xxxxxx and 2.6 million vapers in UK, financed my own exit from smoking and it has repaid me financially to the tune of thousands of pounds over 5.5 years and the improved health – well, I can’t put a price on that. The outlay for a reasonably efficient starter kit can be as little as £25 – for those in real need maybe the provision of ONE of these might be acceptable alongside help from their local S.S.S who can provide advice (or should be able to). After that no, sorry, but when people are being refused cancer drugs by a cash-strapped NHS you cannot justify supporting what is simply a habit, not an illness. The Tobacco Products Directive (EU) comes into being in 2016 – it is an appallingly bad piece of legislation which can be interpreted in dozens of ways, I hope the UK Government will put the health of its citizens first when it comes to implementation, but with Tobacco revenue running at £12 billion p.a. and treatment of smoking related disease costing £2.8/3 billion p.a…….fingers crossed!”
I thought that was enough to take in, but, given the opportunity I’ll encourage them to contact MPs etc and give them my thoughts on a non-medical product being under the aegis of a bunch of Pharma “suits” If the mods read this I may be slung off of course, but I contribute regularly on loads of subjects so they can’t label me a shill!
I edited one typo from the finished post – I’ve just noticed “Phatmaeuticals” and I think it’s quite appropriate!
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A very good view posted by Carl V Philips on the issue, a must read for anyone that is a vaping and THR advocate. Be very careful about how you frame your argument and how you respond to ANTZ, (and PH in the UK is full of ANTZ).
http://antithrlies.com/2015/08/21/ecig-proponents-need-to-learn-lessons-from-other-activists/comment-page-1/#comment-36587
I see this latest report as a way for ANTZ to take control of vaping, and to medicalise and restrict its use and effectiveness to that of an “approved” NRT. The takeover will also allow them to siphon more grant money from the taxpayer and keep the gravy train running.
I don’t agree with this analysis. Before Oct 2013, the whole EU, including and especially the UK, wanted to medicalise these products and regulate under compulsory medicines legislation. We fought that one and won, and now we just have a useless EU directive to contend with – but this is nothing like as bad as classifying the products as medicines (as in Australia or Canada) or what the FDA has in mind in the US. We are not seeing a rush back to mandatory regulation of the products as medicines in the UK. The arguments against this have been rehearsed endlessly on this blog.
Some things to bear in mind about the PHE report:
1. It should be compared with the statements and positions of other public sector public health bodies – like CDC, WHO and their equivalents in Canada and Australia. It should not really be compared with some idea of the perfect statement or evidence review. Gaining agreement to this within government will have been a huge struggle for good people determined to do the right thing. One can find fault of course (and I do) and concentrate on that – but the report is so much better than anything else produced by a public body anywhere in the world that I would rather welcome it and draw on the many good things about it.
2. The key 95% claim is really a risk communication device designed to shift risk perceptions towards reality without implying the products are safe. Whatever the alternative is, it hasn’t been working: perceptions of risk are wildly inaccurate and heading in the wrong direction. I have been urging PHE to ‘own’ the problem of risk misperception (see my dream ministerial letter to English health bodies here) and this is sign that they are willing to take this on. It is not exactly as I would have phrased it (“at least 95% lower” would have been better), but I’m willing to be generous and assume they are allowing a buffer for unknowns and for remaining cautious. They probably had to contend with bureaucrats who didn’t want to say anything, or to fudge and hedge. If everyone believed and acted as though the risks were 95% lower than smoking, we would have achieved a huge improvement in the alignment of perceptions and reality. If there is a better more accessible way of doing it, then I’d like to hear it.
3. It is a report from the public sector, so it shouldn’t be that surprising that it dwells on the public sector role. There is a debate about whether e-cigs are something to use in the healthcare system or other settings where NRT and other medications are currently used and/or paid for from the public purse. But I see that as a kind of endorsement of the idea, rather than an attempt to capture it. The public sector is playing catch-up with the market.
4. I’m not sure who you mean by the ANTZ? The lead authors of the evidence review (McNeill and Hayek) are certainly not that. The key personnel in PHE are not either. In fact, many of the players in the UK are lined up on the right side of this argument and making valuable contributions in their own way within their own communities of interest. Compare the approach of Cancer Research UK (here) with American Cancer Society. Or compare ASH, which has produced lots of useful primary statistics on vaping, with CTFK, which has done nothing but harm.
There’s a lot more that I would like to say, but I just don’t have the time at the moment.
But I couldn’t possibly agree with you more strongly.
I’m from California — Land of the Lunatic Witch Burners — and things couldn’t be much worse (as far as mind bogglingly stupid anti-e-cig propaganda goes, anyway), and this "update" from PHE is like a breath of fresh air I can tell you! o.o
Thank you Clive for your detailed reply, by ANTZ I mean those in TC, and in other areas of PH that are pushing for prohibition of vaping because it doesn’t suit their agenda or ideology. I understand your arguments and agree for the most part, but I see medicalisation as a way to destroy the independent manufacturers of vape products, and to promote vaping as another NRT, along with restrictions on who, where, and what people can buy. This is exactly the direction the tobacco control industry in Australia wants to head, if they cannot get vaping banned and treated the same way as tobacco smoking.
Here is the latest from the well known ANTZ Chapman, who is still clinging to the “wont someone think of the cheeeldren” arguments, as well as pooh poohing the fact that vaping is effecting the level of smoking in the UK and the US. He again suggests that people who cut down using vaping are also not doing themselves any good. As I live in Australia, I hope you can understand why I worry about vaping being portrayed as just another NRT and why I do not want to see vaping medicalised, this would mean that vapers in Australia would have little or no access to vaping as an alternative to smoking tobacco. We already have huge barriers in the way of people who want to make the switch, we have to import all nicotine liquids, and in my state of Western Australia, we have nowhere to buy even the hardware, unless we buy online from overseas, or interstate. We are facing bans on vaping, the same as those on smoking, which are draconian to say the least.
https://theconversation.com/are-e-cigarettes-a-gateway-to-smoking-in-14-year-olds-new-us-data-46468
Here is a link to an article by Linda Bauld, which I welcome,but as you can see by Chapman’s comment, it will likely be ignored in Australia, as the ANTZ here will cherry pick, or simply discount the report because they ignore all research from other countries unless it confirms their agenda or ideology. This positive report on vaping doesn’t do this, as evidenced by Chapman’s comment and propaganda piece.
https://theconversation.com/young-people-and-e-cigarettes-what-we-know-so-far-46243
My response to the JAMA study that Professor Chapman is puffing up out of all proportion: JAMA paper finds some adolescents experiment with stuff – so what?.
As Marcus Munafó, editor in chief of the Nicotine and Tobacco Research journal puts it: Impulsivity data suggests whole thing boils down to: People who try stuff, try stuff…
Thank you Clive, I hope you will post your response and analysis in the comments section of Chapman’s misinformed propaganda piece, when comments open on Monday. Although you are probably as tired as the rest of us are, constantly having to counter this nonsense and lies.
Jude
Comments at the TC on Chapman’s piece are still not open.
Why the Conversation’s editors continue to headline Chapman , when they have ‘down the list’ a much more scientifically literate balanced piece like this https://theconversation.com/young-people-and-e-cigarettes-what-we-know-so-far-46243 is beyond me.
According to Wikipedia Simon Chapman in his ” PhD in social medicine he examined the semiotics of cigarette advertising”. Think that says it all- His only interest is in the, packaging.
Jude have a read of this
http://stopthesethings.com/2015/02/21/on-the-expertise-of-simon-chapman-or-how-to-become-a-self-appointed-wind-farm-health-expert/
John, The Conversation web site loves Chapman because he is click bait, and only ever posts opinion pieces that are controversial because it feeds his ego. He also likes to play the victim, or is incredibly rude to those that comment on his pieces, which also acts as click bait for the web site.
John I had a read of the link you posted, and it was interesting for shining a light on the lack of expertise of Simon Chapman, even if I myself am a supporter of wind turbines, (I have a wind farm very close to my home, and it has been far better for the health of the people in my little town than the previous diesel power plant that is replaced).
As I have said before, I consider Simon Chapman to be a person with narcissistic personality disorder, he fits the classic text book traits of this disorder, and exhibits the text book behaviours of someone with this disorder.
Whenever there is a lull in the tobacco control industry’s push for ever more draconian policies, Simon needs to find another controversial topic to act as a vehicle for his ego, wind turbines just happened to be the one he latched onto this time.
With the rise in vaping over the last couple of years in Australia, and around the world, Chapman has spied another vehicle for his ego driven rantings, his displays of pique on “The Conversation” website, and any other organisation that will give him a platform, is simply another display of his personality disorder. He is on the wrong side of history in the area of tobacco harm reduction, but that doesn’t matter to a narcissist, as long a he is getting attention, he doesn’t care that anyone is harmed by his actions.
This report may be very useful in NSW, the finding of not a issue for bystanders, could be significant. The governments legislation,which would not classify ecigs as tobacco smoke, for the purposes of where you cannot use them,has been languishing in the upper house . The government needs just one of the crossbenchers to have the numbers, and the crossbenchers are not all from the authoritarian left or right. In fact the only thing the legislation prohibits is sale to minors a- it’s pretty good, if it gets through the in economic and population terms ,largest best functioning state of the Australian federation,would also have the most liberal law on ecigs.
I sincerely hope you are correct John, at least those of us outside of NSW will be able to import our vape products from an Australian vendor, even if we risk criminalisation for possessing, and using, vape products in our own states.
Jude hi.
I suppose it could be like the days when there were abortion clinics positioned just south of the Qld border just inside NSW and Queensland’s women would have to ‘ jump on the freedom bus ‘ to access safe professionally done abortions.
Re NSW
I do not have any inside info on this , however my sense of what may well be happening is this: the proposed NSW legislation has been referred to committee and in this case that could well mean that there was such a profound disagreement that there is no possible compromise position (given the totalising ,authoritarian and wowserish leanings of the 3 main opposition groups : Labor ,the Greens and the Christian right , that is pretty likely. And Mr chapman is almost litteraly, just down the road, they would have had plenty of official BS thrown at them as well).
Therefore it would come down to the shooters and fishers party’s votes . However if their votes are critical they could want a potentially expensive favour in some other area of government in exchange for their votes ,for example something on the lines of allowing even more ‘hunting fishing ‘ in National Parks.
If something like that is happening and the standoff continues,indefinitely, then that is not such a bad result. I say that because as it stands ecigs are ,quite rightly ,simply not covered by the laws on tobacco and tobacco smoke, at all.
Which from the perspective of a community minded pragmatic liberal is how it should be,permanently.
There is no ,good, reason for drastic or hasty government intervention,at all. Ecigs are not a health issue for non users, do not impaire driving ability , do not cause users to become aggressive to others late at night outside the pub and so on . And there is no evidence that ecigs are a serious ,urgent ,health threat to users either.
There is no reason to legislate, let alone do it in great haste.
The PHE report simply makes it very clear that the moral panic of the anti brigade is just sound and fury ,is not supported by carefully done proper studies by reputable people i.e there is no good reason for governments to do anything much in a hurry.
The future is of course ‘unpredictable’ but the Baird government has only recently been resoundingly reelected , is more likely than not to continue to do a good job and is likely to be the NSW government for sometime to come.
So their doing nothing re legislation would give several years for people to read reports like PHE and to realise that ecigs are not the end of civilisation as we know it and that in fact ecigs are really a good idea ,and that “they do not smell like smoke ,at all”.
Time will tell.
Thanks for the reply John, I guess I’m at a point where I simply do not trust any politicians to have and common sense at all when it comes to vaping. We also have a liberal state government,(in name only, they are more closely related to fascists than actual liberal thinking people), and I cannot even buy a starter kit here, or no nicotine juice. There are no more B&M shops after the ruling against Vince Van Heerdon, (although this is still going through the appeals process).
It seems that people like Chapman are doing all they can to protect their jobs, and make sure that Aussie smokers do not have easy access to vaping, these people are without conscience, and are driven purely by self interest, and the interests of whoever is funding them. The federal government is full of liars and rorters, and they are addicted to tobacco tax, so I can’t see them having policies in favour of vaping, more likely they will take the lead from the nutters and zealots in tobacco control, and ban ban ban. They have ignored any positive research so far, so I don’t hold out much hope of them taking anything on board that shows positive outcomes from vaping. They prefer to accept the lies of the ANTZ.
However, this is just my personal opinion, I hope I’m wrong and there will be a change in thinking and policy.
Your not wrong about Chapman’s wickedness, the legislation would ban the supply to minors.
Chapman’s proxies in the upper house have blocked that ,because they want a effective ban on what consenting adults do. They are prepared to accept a situation were the one thing we all agree on as essential, is held to ransom, by them, simply to get their own way on everything. Evil.
This is what makes me so angry, all the evidence shows that there is NO gateway effect, and there is little to no possible harms from vaping, for either the vaper or anyone else. So what right do these people think they have to ban vaping for adults, regardless of whether they are smokers or not.
This has always been about the toxic ideology of those in the tobacco control industry, not health. Vaping has been around for nearly 10 years now, and popular among smokers for at least 5 years. This nonsense about waiting decades, because of what tobacco companies did over half a century ago, is simply ridiculous. Apart from anything else, we have far better technology to assess any possible risks than existed decades ago, but the tobacco control industry still try and use this as some type of excuse to ban an orders of magnitude safer alternative.
It actually doesn’t matter if people quit nicotine or not, or vape for as long as they live, these people have no right to decide the choices of adults.
We have a situation in Australia, where people are being criminalised for switching to a safer alternative to smoking tobacco, an alternative that harms no one. The tobacco control industry are destroying the credibility of public health, and must be held accountable for the misery and death they are responsible for with their toxic ideology and greed for money and power.
Chapman can simultaneously, ‘worry about the children’, and sit back and happily watch the blocking of a act of parliament that would ban sales to minors, because it does not go far enough re adults.
On this whole meds and prescription thing. It’s not necessary. Louise Ross has shown the way. All it needs is a scheme comprising B&M shops who are accredited to supply, and vouchers from SSS offices for, say, £60, which should get the new user a decent start. In fact, this is the ONLY way a pseudo prescription can happen, as a medically licensed ecig is impossible under current MHRA rules, and, contrary to what some Pharmacists think, the MHRA is not currently considering any applications for any.
Even if, some day, a med regs ecig does appear, it will, frankly, be crap. It can be nothing else but crap. It must needs be on the same “level playing field” with the already demonstrably execrable and 94% failure rated NRT.
What the DoH needs to do now is to report back to the UK Parliament and recommend that the UK tells the EU to shove article 20 where the squirrel shoves its nuts, as it is demonstrably antithetical to the health of the nation. All other member states should do likewise. The evidence is in, the conclusion is plain for all to see. Vapers and their families need to contact their MPs NOW and insist upon this course of action.
The media is jumping all over the idea that ecigs are to be available on prescription (it’s as though they can’t help themselves but to find something potentially controversial about the news).
If ecigs ever do become licensed medicines, such products will be outdated, of minimal efficacy and certainly no fun. They might serve a purpose for some folk who are really averse to anything non-medical (but I don’t imagine many smokers fall into this category). The one positive I do see in there being a prescription version is that this surely puts an end to the multitude of unjust vaping bans from workplaces to pubs to hospitals.
However, I do see the possibility of free starter kits being given out by SSS – but I see the big ecig manufacturers footing the bill.
This is probably the best solution for all – basic, but effective (and easy to use) 2nd gen kit for the user, additional services for SSS (who are struggling to justify their existence with falling demand for outdated & ineffective methods), the country supports smokers to quit without it costing a penny in hardware and the manufacturers get in first to promote their product to new users, some of whom will keep it simple & stick to what they know.
Job done!
A very good point Fiona, I can see it working just as it does on some maternity wards, where new mothers are given carrier bags full of free baby products as loss leaders in the hope that they’ll continue to use them.
I agree also with your point about the media coverage focussing on the controversial subject of NHS prescribing. It is a red herring and detracts from the real message of the PHE report, which is to rebalance public perceptions on the risks of vaping. It’s not news or even vaguely surprising that a government health agency would wish to make a product available on the NHS which it believes can help to reduce the harm of smoking. Even if I take the cynical view – that the government wanted med regs for all, that the MHRA has completely failed to facilitate the bringing of authorised products to market, and that SSS are struggling to survive faced with competition from ecigs – the most I can say is that a stated wish for these products to be provided on prescription may assist them with their cause.
Ecigs work on a population level because smokers choose to use them. It’s not rocket science. The benefits such as harm reduction via smoking reduction / cessation are sometimes the intention, but for many are a side effect of that primary choice. The medicinal authorisation process will remove almost everything that creates the reasons for that choice from the products which undergo it, which is why no one is bothering (plus of course the extortionate cost involved in rendering your own product unsaleable). If PH want to exploit the harm reduction benefits of a popular consumer product to meet their own goals then I’m happy to say “have a go at it”, but they’ll fail miserably if they don’t recognise the fundamental basis for its success. I’m optimistic that PHE do actually have some understanding of this, and see nothing in the report that would indicate that they wish to ‘medicinalise’ the entire market as some have been suggesting.
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With the dust now settling it should be noted that the report only says truthful, realistic things about safety not effectiveness.
“There is no evidence that EC are undermining the long-term decline in cigarette smoking among adults and youth, and may in fact be contributing to it.”
“emerging evidence that EC can be effective cessation and reduction aids.”
“These findings, to date, suggest that the advent of EC is not undermining, and may even be contributing to, the long-term decline in cigarette smoking.”
“It is not known whether current EC products are more or less effective than licensed stop smoking medications”
“Whilst other factors may be contributing to the decline in smoking, it is feasible that EC may be contributing to reductions in smoking over and above any underlying decline”
I make no apologies for repeating the ONS’s truth
“The proportion of adults smoking in Great Britain has generally been declining since the survey first included a question about smoking in 1974, from 45% in 1974 to 20% in 2012. Most of this decline happened between 1974 and 1994. The proportion of adults smoking continued to fall between 1994 and 2007, but at a much slower rate. However, from 2007 to 2012 the rate of smoking has remained largely unchanged. While the proportion of women smokers has continued to decline over the past five years, the proportion of males smoking has changed very little.”
Had it been plain packaging rather than ecigs that had created 1.1m GB quitters,one suspects the TC response would have been rather more enthusiastic!
An amusing little aside – the report notes:
“Since then, the number of NRT products has proliferated such that there are now several different delivery routes and modes and countless different dosages and flavours.”
In his letter to MEPs 2 years ago lobbying for medicinal regulation,Mr Hunt notes
“Nicorette has 21 different medicines in its range of forms — gums in several flavours, invisible patches, nasal sprays, mouth sprays — proving that medicines regulation need not suppress the range of products. The pharmaceutical industry is extremely innovative.”
TC academics obviously struggle when they run out of fingers and toes!
Clive can you reassure me that in the wider health system it is not normal for people whose doctoral thesis was on ,the semiotics of advertising…to have positions of considerable authority?
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So wait, the widely-publicized “95% safer” figure turned out to be a parroted guess?
Say hi to all my friends at the University of Saskatchewan!
Sadly, as a ‘reader of studies’ you’ve been very easily played – taken in by a cheap stunt by unscrupulous people who do not wish consumers to have realistic information on which to form risk perceptions to base decisions on whether to try vaping as a way to quit smoking. The number quoted by PHE (95% lower risk) is designed to correct a massive misalignment between perception and reality (many smokers believe there is no risk reduction or the reduction is small) thanks in part to the newsflow emerging from junk studies published and spun in North America.
As I have said in this post, there is consensus among the academics here who work in the field (not the media ranters) that the toxicology, chemistry and physics of vapour present exposure risks to vapers that are likely to be at least 95% lower than smoking (dozens of studies support that view). Most of the toxic constituents in cigarette smoke are not detectable or are present at levels far below 1/20th. This is the expert consensus here and it remains unchanged by the efforts to smear this report and its authors. To beleive otherwise, would suggest that smoking is not that risky.
Further reading:
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00042-2/fulltext?rss=yes
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/456704/McNeill-Hajek_report_authors_note_on_evidence_for_95_estimate.pdf
I hope things improve soon in Canada. I’ve yet to understand why the Canadian approach of restricting consumer choice to only those products known to be deadly while excluding the much safer alternative makes any sense – maybe as a ‘reader of studies’ you could direct to the studies that support this approach.
CB
Please don’t confuse my annoyance over the echo-chambered 95% safer “conclusion” with a belief that these products are less safe. It is quite possible to hold the view that they are very safe indeed, while still acknowledging that existing data do not exist to support a specific quantitative figure widely represented as quite definitive.
Even if we suppose that e-cigarettes are in truth 99% or 99.9% safer than cigarettes, which they may well be, it seems mendacious at this point to represent ANY figure with the certainty trumpeted in PHE’s borrowed “95% safer” estimate. Truthfully, this is a (very) educated guess based not on epidemiological data but on the products’ constituents; we know very well that a 95% lower concentration of chemical X doesn’t have some automatic linear relation to 95% lower health risk. In fact, I think we agree that it is likely LESS risky. But a specific quantitative statement has been made and repeated with poor transparency regarding the evidence base, apparently with the expectation and hope that the number would be widely influential. Wow!
This sort of oversimplification is a problem on both “sides” of the discussion, and those of us trying to parse organizational reports like the PHE document become frustrated when we see this pattern. In honesty, I have seen the single-citation-amplification play out more often on the side of massively over-stating risk. (Again, I think we agree on more than my hasty note let on.)
***
As for the “Canadian approach,” I don’t think that I wrote anything in support of it, don’t know what you think the situation is here, and can’t see why I would provide studies in favour of policies I don’t support myself. I will understand if you are not informed on the current picture in little old Canada, but one can actually buy e-cigarettes and juice in any city in the country since there is essentially no enforcement at all around sale of the devices (to adults). I suspect there will be product regulation in the US and on your side of the ocean before it happens here.
Cheers.
Seems to involve the problem of how to be precisely vague about scale categories and adjectives and nouns.
For example if speaking to a intelligent alien a statement such as ‘ I saw a small elephant, and then I saw a large mouse’ could be confusing, if that alien knew what small and large meant but had no knowledge of what the words , elephant and mouse actually referred to?
While it is true that vapors are stil inhaling something, it is definitely not the product of incomplete combustion, is chemically quite different and also much less chemically complex, than smoke. Therefore surely it should be possible to in a , precisely vauge way ,quantify the intrinsic differences of scale, for the risks of inhaling lots of smoke on a regular basis, versus the risks of smokeless ?
That’s a more interesting and articulate comment than your initial contribution – thank you.
The purpose of providing a quantified estimate is to help others (especially those whose lives are at risk) their risk perceptions more closely aligned with what experts believe. While it is possible to make a more technically correct, qualified, caveated and hedged statement of risk, this may not have the effect of actually moving public perceptions closer to the expert assessment. I describe this as a question of who bears the “being wrong” risk? The habit of official sources is to shift the “being wrong” to the public by not providing easily grasped anchors for risk perception. The problem with this is that the public left to make its own mind up is wildly wrong about this. So in this case, in the name of clear communication, PHE has accepted a minor “being wrong” risk in order to help the public be much more right. PHE’s estimate is not just based on Nutt et al – but on a wider assessment of the chemistry and physics of vapour, the absence of any studies giving grounds for concern so far, some confidence that regulation will weed out rogue products and with reference to what we know of smoking. It is cautious – the most likely risk is far lower than 5% of smoking based on vapour toxicology, but there is a small probability that it could be higher than 5% smoking if there is some unknown mechanism not so far detected… however, we would expect that mechanism to found early and corrective action taken in a way that smoking risks never were addressed. So even in the worst case, this is small realistic risk to health.
Agreed – you have no need to justify the Canadian status quo. A well-developed black market may actually be superior for health compared to what is envisaged in the EU and US, so it may be that Canada is again a leader.
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