Professor Simon Chapman of the University of Sydney has used his BMJ blog platform to mount a quite personalised attack on my views on e-cigarettes drawing bizarre conclusions from imagined inconsistencies in statements I made about completely different things separated by 15 years and a lot of change. I’ve submitted a comment to the BMJ, but for all I know it will be held in moderation for days while the blog is circulating freely. So here is a copy of my attempt at a dignified response.
Professor Chapman’s blog is largely based on comparing what I said in a report for Action on Smoking and Health (ASH) in 2000 about the conduct of tobacco companies with what I and many others are saying now about e-cigarette advertising. The key weakness in Professor Chapman’s argument is that the statements he compares were about two different things in a completely changed context.
My 2000 ASH report “PR in the Playground” was not just about tobacco companies: it was mainly about the useless and cynical youth anti-smoking initiatives run by tobacco companies. Tobacco companies running campaigns to persuade young people not to smoke were never going to be convincing or effective and that report shows why. They were mainly about protecting the reputation of tobacco companies – hence the ‘PR’ in the title. I haven’t changed my views about those programmes one bit, though I don’t know if they still exist.
But e-cigarette companies do not have programmes like this to my knowledge and Professor Chapman doesn’t suggest they do. My recent statements were about e-cigarettes, not cigarettes – another important difference. So he is comparing statements I made 15 years ago with statements made recently about something completely different in a radically changed landscape: there were no e-cigarettes in 2000. It’s not that surprising the statements look different.
I hope that Professor Chapman is fully aware of the potential dangers built into the positions he holds. It would be a major public health error to treat cigarettes and e-cigarettes the same way, given the very significant differences in risk – e-cigarettes are likely to be at least 95% lower risk than smoking, based on what we know of the toxic constituents of vapour. For example, an important effect of banning e-cigarette advertising could be to protect the incumbent cigarette trade from competition from a disruptive low-risk technology that helps people to quit smoking – thus increasing harm. In the UK, we have evolved a quite pragmatic approach to controls on e-cigarette advertising, which is similar to that used to control alcohol advertising. You don’t need a total ban to deal with the odd rogue advertisement (and it will always be possible to find these in any sector). The UK Committee on Advertising Practice reports that the e-cigarette code is working well and shaping the behaviour of advertisers in the way intended.
We rightly ban tobacco advertising in the EU because smoking kills 700,000 EU citizens per year. But no such justification exists for banning e-cigarette advertising. The most likely effect of e-cigarettes is to reduce the smoking-related death toll in future – a negative death toll – assuming they are allowed to compete.
The problem of unintended consequences goes beyond banning e-cigarette advertising. Much of the hostility towards e-cigarettes in the field of tobacco control, if translated into policies, misinformation or taxes, could have the effect of protecting cigarette sales and supporting smoking. I hope Professor Chapman will reflect carefully on what harms might be caused if his ideas are taken seriously by policy-makers.
I also made what I think is a reasonable point about the incentives of the companies involved: that the e-cigarette sector has a very large market of adult smokers to pursue as their potential customer base (this also applies to the tobacco owned e-cigarette companies who are fighting over market share). The data show that their customers are overwhelmingly adult smokers. The e-cigarette sector is small in every country compared to the cigarette trade (about $6 billion globally compared to $800 billion for the tobacco trade) so there is plenty of room to grow by eating into the cigarette trade. These companies would create unnecessary risks for themselves if they targeted teenagers, and they have no need to.
Even if not targeted, some teenagers will use these products. Most public health experts are familiar with the idea that some adolescents engage in risky behaviours and try adult things, and I hope that isn’t a revelation to anyone in the field of tobacco control. The data show that the teenagers who do use these products are almost all smokers already or have ‘risk factors’ that mean they are likely to become smokers. To the extent it is displacing smoking, e-cigarette use may be creating a health dividend. It’s too soon to say if that is actually happening, but the trends are largely consistent with that effect and Professor Chapman should expand his thinking to accommodate that possibility.
As far as consistency is concerned, in 2000 while still Director of ASH I was open-minded about the concept of the tobacco market evolving to low-risk nicotine products and even envisaged the challenge that this would create for some factions in the public health establishment. See my paper ‘What is the future for the tobacco industry” from Tobacco Control journal in 2000 and especially the section “How can the tobacco market evolve“, in which I imagine the rise of products a bit like e-cigarettes…
Imagine a hypothetical new product—let us call it “Satisfaction”. Assume it has the nicotine delivery of a Marlboro cigarette—not only the same dose of nicotine but the same speed of action and “impact”. To make it palatable it has been flavoured, perhaps with something fashionable like tequila. As an ironic marketing gambit, a hard living cadaverous rock star has been enlisted to endorse the product. It is packaged like “poppers” (capsules of amyl nitrate) and sold initially in bars and clubs to give it an “underground” feel. Of course, “Satisfaction” is powerfully addictive and the nicotine has effects on the heart and other health consequences. It appeals to the young and there is concern that teenagers might start to use it. In many respects, it is similar to a Marlboro cigarette, except that it does not expose the user (or people nearby) to inhalation of 4000 products of tobacco combustion and greatly reduces the risk of disease associated with long term nicotine use. Even if it is not entirely safe, “Satisfaction” is far less harmful than smoking tobacco.
What would you think about this product? Would you fight to ban it, or fight to have it introduced? I would want it introduced. It is an alternative that introduces no new risks that are not already present with cigarettes, but greatly reduces smoking related health risk. The truth is, however, that we are unlikely to be asked. No pharmaceutical regulator would approve “Satisfaction”, and knowing the impossibility of bringing such a product to market, no food or drug company would even begin any sort of development.
Underpinning this view is a clear distinction between the use of the drug nicotine and the harm caused by its manner of delivery. This is a crucial distinction—health promotion efforts have implicitly tried to tackle the harm and the underlying drug use simultaneously. This approach has had some success with some groups in some societies. The problem is the remaining people who continue to take nicotine by smoking tobacco. For them, it is possible to tackle the harm caused by the manner of delivery independently of the drug syndrome. This is not to say that nicotine dependence should not be tackled, but “drug problems” are social phenomena and should be tackled by addressing the underlying socioeconomic and cultural causes, backed up with treatment for dependence.
My article from 2000 is not perfectly correct about the rise of e-cigarettes, but as a bit of crystal-ball gazing it is not a bad account of what has come to pass. Neither is it inconsistent with what I’m saying now. I was warning even then that we would need to put health first if the market evolved in this way, which it duly has done: leaving the much of the tobacco control community confused about its mission. What I said in 2000 about the future of the nicotine and tobacco market is, I think, a fairer test of consistency of my approach to e-cigarettes than what I said at the time about something completely different.
Regrettably, this blog contains unfounded innuendo about my purpose that readers should discount. I don’t wish to engage Professor Chapman in personal animus, but I would like to explain my own motivation. I believe the ‘harm reduction’ agenda is a legitimate strategy in drugs, sexual health, alcohol and other fields within public health – and there is every reason to apply it to smoking. I have been consistent about this since 1998. I put a lot of time into this issue because I believe it has the potential to avoid hundreds of millions of premature smoking-related deaths in the 21st Century by making the cigarette obsolete for many or most users. Furthermore, I think it is consistent and synergistic with legitimate evidence-based tobacco control policy – the more you press people to stop smoking with punitive or coercive measures, the more important it is to have somewhere for committed or addicted smokers to go. That’s an ethical argument that tobacco control advocates would do well to embrace if they wish to succeed in their mission.
End of posting.