May 24th, 2016

Are they nuts? The dysfunction and decadence of tobacco control in one chart

The chart of an audience poll from the Global Tobacco Dependency Treatment Summit 2016 (23-24 May 2016, twitter:#TDTSummit16) is deeply disturbing…

Continued cigarette smoking is favoured by two-thirds (66%) of the audience, rather than using an e-cigarette. Are they nuts? The question generously even allows e-cigarettes to be a ‘not ideal’ compromise, but still the majority would rather have people smoking. Who is in the audience? The summit is…

…bringing together world leaders in tobacco control and treatment, international and national grantees, and health care professionals, to network, share best practices, inspire, and empower participants to build capacity for treating tobacco dependence around the globe

In theory, these are professionals trying to contain the ‘smoking epidemic’, but voting to extend it. If evidence was needed that “tobacco control” has become a dysfunctional and decadent enterprise on which no more money should be squandered, it is right there on this chart.

Acceptable to whom? The use of an e-cigarette instead of smoking is a private transaction undertaken by a smoker making a free-choice and executing it with a purchase from a vendor. On what basis does this audience have a locus to declare this transaction acceptable or not? Any more than they can decide whether what I had for lunch today is acceptable or not. Why are they involved?

Or then what? For those audience members who find it ‘unacceptable’, now what? What should they do, given they are not involved directly? Throw themselves under a bus, consumed by impotent anguish? No, it’s far worse than that. They will get busy: write misleading articles, give bad advice, make irresponsible statements and petition governments to have their preferences imposed by law over the actual adult parties to this private and personal, health-enhancing decision. That’s the disturbing thing – it’s so illiberal, intrusive and abusive – utterly lacking in empathy, humility or any concern for the people at risk. They will try to stop people stopping smoking, just because they aren’t stopping smoking in the way this audience wants. But why…?

Tobacco Dependence Treatment? What they were probably trying to say in the poll (but didn’t actually) is that they think is that other approaches (i.e. pharma or other medicalised approaches) would be better than e-cigarettes irrespective of whether the person wants to use that approach, whether these approaches have failed in the past, or even that the smokers concerned may consider that they don’t need ‘treatment for tobacco dependence’, they just don’t want cancer if they can avoid it. Maybe this statement, under the summit resources, offers a clue…?

Since 2012, SCLC and Pfizer IGLC (Independent Grants for Learning and Change) collaborated to award over $6.5 million in grants focused on smoking cessation to 54 organizations nationwide. A group of expert reviewers and SCLC volunteered assistance to this grants program and received no financial remuneration from Pfizer. Grant funding for the 54 awardees is provided entirely by Pfizer.

Global Bridges. The other main partner in the summit, with Mayo Clinic, is Global Bridges. It isn’t transparent enough to declare its actual funding source on its web pages (at least that I could find) but it does mention that it is disbursing Pfizer grants internationally. Update (via @JoodiG’s tweet) – see this 2013 post by Mike Siegel: Mayo Clinic researchers who oppose electronic cigarettes fail to disclose pharmaceutical conflicts of interest in research

Protagonists in the war on nicotine. This does suggest concern over the confusion over goals in tobacco control (Who or what is the WHO at war with?) is a problem that justifies careful examination. Confusion over goals may also be driven deliberately by pharmaceutical companies with interests in psychoactive drugs for tackling ‘tobacco dependence’, though this is no longer a reliable proxy for tackling ‘harm’. It never was in the case of smokeless tobacco – as we know the Mayo Clinic has form in misleading people about smokeless tobacco, so maybe this really is a deep confusion of objectives that has taken hold on this redoubtable pillar of the medical establishment.

Conflicts of interest. It’s to treat pharma money with just as much caution as tobacco money. We need to start calling out more forcefully those situations where pharma commercial interests have an obvious conflict with pathways that benefit health, and therefore – like the tobacco industry – cause smoking related ill-health. I’m sure everyone has noticed the volume of anti-vaping propaganda that pours out of the pharma-funded health meetings like the American Thoracic Society annual congress – it would be hard not to. But they keep getting away with it – unchallenged by journalists and, of course, from within the ‘discipline’ of ‘public health’ (the quotes are necessary).

Try not to be quite so nuts. To every participant at#TDTSummit16 who didn’t vote “A”, may I suggest that before returning to work and causing any further harm you should read this paper by two genuinely thoughtful public health experts (no quotes needed), Lynn Kozlowski (University at Buffalo, SUNY) and David Abrams (Truth Initiative):

Kozlowski LT, Abrams DB. Obsolete tobacco control themes can be hazardous to public health: the need for updating views on absolute product risks and harm reduction. BMC Public Health 2016;16:432. doi:10.1186/s12889-016-3079-9 Conclusions The last 50 years of tobacco control in the U.S. have regularly engaged issues of absolute risk and harm reduction, but have done so in varying ways (see Table 1). The recognition that cigarettes were deadly when used as intended and more lethal than a number of other unsafe products combined was influential and important in the progress of tobacco control. In subsequent years, other forms of tobacco use were treated as similar to cigarettes in issues raised [42]. It is important to make clear distinctions between the classes of tobacco/nicotine products as they differ substantially in risk to the user and to focus tobacco control efforts on reducing the use of cigarettes and other combustible products (see Fig. 1). Complex models [42, 53] should be employed in tobacco control in order to not treat products with large differences in risks as if they are the same [31]. A new reframing of leading themes can align action plans to more powerfully and rapidly achieve population-level benefit and minimize harm. The goal of updating the framing with a new synthesis of management of all forms of nicotine delivery is to eliminate use of the most appealing, addictive and deadly form of tobacco delivery in our lifetime – the smoking of combustible tobacco products – and thus expeditiously prevent the premature deaths of 1 billion people projected to occur worldwide by 2100, if the contentious debate is not resolved.

Or at least think about what you just voted for.