Louise Ross, head of the Leicester Stop Smoking Services, took part in a debate on e-cigarette in front of an audience of respiratory nurses. It didn’t go well.
In this guest blog, Louise describes her experience debating e-cigarettes and tobacco harm reduction with a consultant in respiratory medicine apparently prepared to say anything to rubbish e-cigarettes.
Her account starts here:
It was a session I had really been looking forward to – the chance to tell a conference full of respiratory nurses the good news about e-cigarettes, and how they could help their long-term smoking patients improve their breathing, by switching from tobacco cigarettes to e-cigarettes.
I’d prepared a presentation I was proud of, bringing together what experts in the field say (Robert West, Peter Hajek, John Britton, Ann McNeill, Linda Bauld), and what Public Health England say, with an added sprinkle of what our own stop smoking advisors say (real-life examples of patients with complex COPD, for example) and what service users say (‘It was a revelation’).
I’ve done lots of similar talks before, and have always been delighted with the way the audience visibly moves from sceptical to interested to welcoming of the notion that e-cigarettes could have the potential to get people away from smoking, and that even more importantly, people enjoy using them.
What I hadn’t factored in, naively, is that with me being the ‘pro’ speaker, the ‘con’ speaker would be willing to trot out every cynical ploy we’ve ever heard, to convince his audience that they could actually be responsible for the ghastly death of their patients, while helping the tobacco industry multiply its profits. Here’s just a sample:
‘They’re all made by British American Tobacco’ – BAT has much less than 10%.
‘There is no information on the packaging’ – there is plenty of info and consumers aren’t complaining.
‘They are not regulated in any way’ – they are regulated as consumer products and at least 17 EU directives apply – E-cigarettes are unregulated, right? Wrong!
‘Everything good you read about them has been ghost-written by the tobacco industry’ – PHE evidence review, NCSCT briefing on e-cigarettes , and ASH briefings really are not by the tobacco industry. Many independent academics are positive – take this example Professor Robert West and Jamie Brown in the British Journal of General Practice. There is no evidence of tobacco companies ghost-writing anything, let alone everything – and no evidence has been presented to show they have.
‘We don’t know anything about them’ – this is all too true of certain individuals in the health community, but many public health professionals regard it as an ethical responsibility to be knowledgeable and truthful about them
He quoted the Hong Kong study comparing vapour with terrible air-quality, rubbished as completely implausible within minutes of publication here.
He emphasised that there is no clinical control over the amount of poisons in them – ‘clinical control’ is unnecessary and inappropriate, and no-one is being poisoned.
He lamented the fact that people can buy any devices without the supervision of a clinician – perhaps he would rather it was harder to buy e-cigarettes than cigarettes?
He seemed enormously troubled with consumers making their own choices and dealing with smoking in a way that works for them, and he felt that only by strict standardisation could we ensure anything approaching patient safety – no such restrictions apply to cigarettes.
He described patients harming themselves – some apparently even use an e-cigarette while they are still smoking! An awful choice apparently, doubling the risk they were exposing themselves to – he was probably referring to and misunderstanding ‘dual use’, often part of a pathway to switching completely.
He said one of the chemicals ‘discovered’ in the e-liquid was propylene glycol. ‘Do you really want your patients breathing this stuff in??’ he pleaded – PG has not been ‘discovered’, it’s a key ingredient and is the e-cig alternative to delivering nicotine on smouldering tobacco smoke particles.
As I was scribbling notes so that I could address these points during the debate to follow, I cringed as the audience seemed to loudly murmur assent, or shake their heads in unison, or gasp with shock as he claimed to have received personal threats from the tobacco industry and e-cigarette manufacturers (because they’re all the same, aren’t they!) – it is hard to imagine any e-cigarette company threatening anyone – no company would be that foolish – and no evidence was presented, of course.
The loudest audience gasp though was for the final full-screen slide, the picture of the man who had half his face burnt off by an exploding vaporiser. I can’t recall the exact words he used for commentary, but the meaning was clear – this is what you invite if you tell your patients they can vape – the irony is that battery safety would be a useful subject for regulation, but regulators have paid little attention to this while they wasted years trying to misclassify the products as medicines or negotiating really poor regulation in the TPD.
Some jaw-dropping observations came from the delegates: one reminded us all of the other momentous time when patients described something as a revelation – thalidomide. Another suggested that if a COPD patient was near to death, this could be an appropriate time to allow vaping, but certainly not for younger patients – do they think that people should smoke until they are almost dead or until e-cigarettes have somehow provided the impossible proof they don’t cause every conceivable condition?
The outcome… Sadly, there was hardly any opportunity to put the record straight or to discuss the evidence dispassionately. The vote at the start was in answer to the question ‘Would you encourage your patients to use an e-cigarette?’ 33% said they would, 67% said no. At the end, only 17% would, the No group had increased to 83%. Although the vote was a horrible moment for me, there were a few moments of sunshine in the gloom. Several people came up to me afterwards and said they wholeheartedly agreed that e-cigarettes could be a life-saver, and some of these had seen the benefits at first-hand, among friends and family members, reminding me that in the abstract, for clinical staff, imagining the worst outcome may prevent them taking risks with patients to whom they have a duty of care.
Also, many people took down the details of the new NCSCT guidance on e-cigarettes, and I can only hope that when NCSCT says that nicotine does not cause cancer, people believe that rather than the speaker, who said it might.
I left saddened and concerned. A cadre of health professionals had been misled by clichés and wild propaganda points into rejecting something we know could really help their patients. When we debate, we should keep in mind the seven principles of the Public Health Registry Code of Conduct for public health professionals
- Make the health and protection of the public your prime concern
- Maintain high standards of professional and personal conduct
- Be honest and trustworthy
- Protect confidentiality
- Respect the dignity of individuals and treat everyone fairly
- Know the limits of your competence and act within them
- Cooperate with the teams with which you work and interact
If we reduce our debates to a slugging match, truth, subtlety and complexity will never win. It seems to work for Donald Trump, but it has no place in public health.
Post-script: Dr Andy McEwen, Director of the NCSCT, has since offered to get a copy of the e-cigarette briefing to all attendees, to try and undo some of the damage that was done on the day.
9th March 2016 (No Smoking Day)
Update: Clive Bates adds…
A message from one doctor to another.
The stubborn blinkered idiocy of some Drs is staggering! A resp consultant spreading such negligent lies is heinous. https://t.co/WWQdui63EU
— Dr Christian Jessen (@DoctorChristian) March 10, 2016
Who was the respiratory consultant talking such utter ill informed bilge and stultiloquence? I’d SO love to know! https://t.co/WWQdui63EU
— Dr Christian Jessen (@DoctorChristian) March 10, 2016