July 3rd, 2014

Turning the tables on public health – let’s talk about the risks *they* create

I’ve had enough of the one-sided conversation about the risks associated with e-cigarettes… poisons, gateways, renormalisation, fires, explosions, MRSA, pneumonia, dual use, undermining tobacco control, nitrosamines, anti-freeze, particulates, heavy metals, dead dog, dead cat…. blah blah blah.

ENOUGH! The public health establishment is conspicuously failing to recognise the risks associated with its preferred policy responses to e-cigarettes: with not having e-cigarettes, with banning snus, with prohibiting vaping in public places, with confusing people about risks, with controlling everything. They carry on as if these risks are zero or somehow not their responsibility – but they are all plausible and all end in more smoking and more cigarette sales. We need to press them much more assertively on the risks they create and the harms their ideas may do:

“do you accept these risks are plausible and can you see how and why they might arise?”

“what evidence do you have regarding these risks?”

“what make you so confident your policy ideas will not cause more harm than good?”

“at what level of risk would you stop advocating these policies, or at least call for more evidence?”

For almost every policy idea there is for regulating harm reduction, there is a realistic risk that it will make things worse for health. And for almost every theoretical risks from vaping, there is a more plausible theoretical benefit. Let’s consider the following:



1. Insisting on pharmaceutical regulation. Do advocates of pharmaceutical regulation regulation like ASH and Royal College of Physicians really know enough to be sure that their policy would not dramatically reduce the diversity of products available, raise costs, smother innovation and deny some users the products they find most effective as alternatives to smoking? Yet their preferred policy comes with that major risk, and with the consequence that more people may smoke more cigarettes and the toll of disease and death will be higher. Have they ever acknowledged this risk or shown that they are willing to accept responsibility for adverse consequences arising from their policy preferences? I have seen little evidence that the recognise this risk as something very serious and potentially significantly larger than the risk they are trying to address.

2. Banning vaping in public places. Organisations like the BMA, Public Health Wales and Faculty of Public Health seem to have never considered that their policy in favour of banning vaping in public places may diminish the value proposition for switching to e-cigarettes from smoking and cause more smokers to persist with smoking. Have they ever accepted that sending vapers outside to join the smokers may cause more relapse to smoking? Where is their account of the potential lost benefits that might arising from normalising vaping in public places, and thereby encouraging more smokers to switch? They are totally silent on these points, have no evidence to suggest these risks are nugatory and accept no responsibility for the harmful consequences that might arise.

3. Disinformation. It is staggering that such a high proportion of smokers believe that vaping or smokeless use is no less hazardous than smoking, or not much less. Have any of the privileged but unaccountable academics in public health ever recognised that they may be culpable in misleading people into remaining as smokers because they are unsure whether there is any risk reduction or much benefit? Or that they have been inspired to fear hypothetical risks that have negligible magnitude? When Professors Glantz, Daube, McKee and Chapman sign up to a letter full of falsehoods, half-truths, misrepresentations and spin, do they worry that the chain of events that flow from this might leave yet more people dying of cancer and heart disease? I’ve never seen any recognition that the likely outcome of opposing products 95-100% less risky than smoking might be harmful. Or that they have even the slightest sense of responsibility for the harmful consequences of their propaganda war.

4. Advertising that scandalises them. There’s lots of public health advocates quick to be offended by edgy e-cigarette advertising or to declare that it is aimed at children and should be banned. But are they accounting for the risk that this sort of advertising actually works well with the target market (and doesn’t usually include them) and may drive more switching – a positive health gain. It’s hard to prove, except that is generally what the advertisers are trying to achieve and the e-cigarette category is growing rapidly – so something is working. Has Cancer Research UK reviewed its hostile stance on e-cigarette marketing and considered the idea that there are risks with banning or severely restricting e-cigarette advertising – and these may mean that more people will smoke? I must confess I have never seen any of the public health establishment weigh this up.

5. Banning snus. A bunch of creepy Brussels-based ‘health’ lobbyists went and told the European Commission in 2012 that snus should remain banned in the new directive. The EU duly obliged, fortified by support from these wholly unaccountable, unrepresentative and harm-inducing public health zealots, whatever the vast body of evidence and expert opinion says to the contrary. But did these supposedly experienced tobacco control advocates pause to consider that denying people outside Sweden access to snus might lead to their death? Have they taken on board the risk that denying what has been so positive for health in Sweden and Norway might actually cause harm in the rest of the EU? You see ‘we just don’t know’… that is, they don’t know whether their actions are causing harm (they almost certainly are) but somehow they don’t feel accountable for this. None of those involved in getting snus banned in 1992 has seen fit to resign or apologise following the success of snus where it has been allowed. I’ve already discussed the negligence James Reilly and the other politicians that agreed the snus ban in the EU Council.

6. Smoking cessation services shunning e-cigarettes. Have the people behind the (NICE) guidance on tobacco harm reduction actually considered that their guidance may be causing net harm? In limiting the use or recommendation of e-cigarettes through UK Stop Smoking Services to only licensed medicines, they may have denied smokers the choice of products that could be effective in getting them to switch from smoking to vaping. Worse still, they may actively dissuading people from trying e-cigarettes who have come in to ask for advice on quitting. Has the health risk associated with the pedantic of requirement that only products licensed as medicines can be used in Stop Smoking Services ever been considered? If the restriction had been lifted or never imposed, maybe there would have been more successful switchers. We may not know the answer to this question, but it is a risk to health – and one likely to be far greater than the benefit to health arising from the insistence on only using licensed products. So who is taking responsibility for these risks?

7. Protecting the children. There is almost universal consensus, including almost the entire e-cigarettes and tobacco industry, that under-18s (let’s call them adolescents rather than children) should not have access to e-cigarettes. But have they recognised the risk here? In the US we know that over 15% of high school students smoke cigarettes (in the last 30 days). But for these smokers why should harm reduction start at 18? Why deny them ‘harm reduction’ alternatives? How do the supporters of this policy assure themselves that e-cigarettes do not function as an alternative to smoking and divert young people away from smoking onset in their teens? It hardly unprecedented because that’s what happens with snus in Sweden and Norway. So all the people who like to use children as a force majeure argument that justifies just about anything – how do they know they aren’t increasing the risk that more kids will smoke?

8. Banning ‘kiddie’ flavours. How much care have they taken to check how many adults like flavours that are supposedly ‘targeted at children’? Have they made any estimates of whether fewer adults will take up or stick with vaping if they are denied these products? How did they decide that adolescents would be attracted to childish flavours, rather than adult flavours? It’s not obviously the case: kids do adult things to emulate adults, not to assert their childishness. So an unproven assertion about flavours targeting children, may lead to more harm in adults… where is the public health recognition of that?

9. E-cigarettes: it’s Lights all over again. This analogy is precisely wrong and designed to cause harm. With light cigarettes, there was no reduction in harm but regulators encouraged smokers to believe there was. With snus and e-cigarettes, there is a dramatic reduction in risk, but regulators seem determined to conceal this important fact from smokers. How much responsibility do the users of this sleazy rhetorical device take for the misinformation built into it? How responsible do they feel for any smokers who says “well I won’t get fooled again” and continues to smoke? What effect do they expect this analogy to have? It’s not a rare occurrence: recently 129 badly informed public health establishment figures wrote to the WHO to make this point:

Public health embraced cigarette filters and “low tar” cigarettes as harm reduction strategies before manufacturers provided evidence and at a time when the manufacturers were well aware that these technologies did not actually reduce harm but were designed to promote cigarette sales by reassuring a concerned public that the new products were safer.

Really… it’s not the same – but it is misleading and therefore potentially harmful to imply it is.

10. Saving or killing the Spanish smoker? Following a campaign of black propaganda and know-it-all doctors talking bollocks about e-cigarettes in Spain, ‘health campaigners’ appear to have achieved a huge decline in vaping. Presumably a ‘victory’ for a certain kind of campaigner – but how many of them are scrutinising the consequences for those Spanish citizens no longer vaping? Are they smoking again? Are the health people involved even bothered?

11. Legal bans on e-cigarettes. Presumably in the nicotine idiocracies of Australia and Canada where they have outlawed most form of e-cigarette commerce while allowing sale of cigarettes, the policy intent would be to have no-one vaping at all… do any of the ‘giants of tobacco control’ in these countries ever cast their eye over the extremely positive statistics from the UK and just have one moment of doubt that they may be preventing something similar happening where they are? In UK 700,000 e-cigarette users are ex-smokers? What are the numbers for Australia and Canada – and who is willing to take responsibility for the missing vapers?

12. Strength limits for liquids. (H/T Sarah Jakes) – so to somehow protect people from nicotine poisoning that they aren’t actually in any danger from to start with, a limit should be placed on the strength of liquids on the market? But have they considered that the stronger liquids are more important for people making their initial switch and may be more important for the more nicotine dependent smokers? So who in public health shouted out about the risks from this limit. Some scientists did, but the wasn’t much to be heard from the public health establishment. And staying quiet is not much different to supporting it.

13. Black markets and DIY (H/T Sarah Jakes). All these campaigners who want bans or hard restrictions are really just saying they would rather the supply was through the grey or v black market or people took the initiative and make their own, with what flavours, strengths and volumes they bloody well want. This is a classic constraint of the unfettered bossiness of regulators and health campaigners – push them too far, raise costs too much, restrict choice too much and the consumer will defect – and a willing but illegal or quasi-legal supply chain will meet their needs – possibly with far greater risks than would have been incurred had there been no regulation at all. So the activists who want to sharply constrain or ban e-cigarettes – where is the calculation of the risks arising from a black market? Or are they just wishing that away? Update – great post on this subject by Carl Phillips 4th July: Predicting the black market in e-cigarettes. He lists six options open to vapers after introduction of highly restrictive (FDA) regulation:

Use the regulated mass-market cigalike products that FDA approves? Vape zero-nicotine liquid? Return to smoking? Switch to another nicotine source like snus, and perhaps continue to vape zero-nicotine liquid? Continue to buy hardware and buy the liquid you want on the black market? Continue to buy hardware and try to make your own liquid, by adding pure nicotine to zero-nicotine liquid, or from scratch?

Of course, FDA, MHRA, EU, WHO have made no assessment of which of these models would predominate – and whether risks and harms would in fact increase overall. They probably just hope that people will quit altogether if they can’t get nicotine in the form they like. Even if the regulators could shrug and shirk responsibility and claim it’s a law and order issue, a real public health perspective takes into account what people actually do, even if that is illegal or mad.

Finally… of course, chronic harm arising from the steady debasement of trust in public health and harmful consequences that might arise when they do have something legitimate to say – a point well made here:

@Clive_Bates Broader risk: I 4 1 no longer believe “public health”; they lie about #ecigs, & so what else? Can’t be trusted about anything. — AgentAnia (@AgentAnia) July 3, 2014

And nicely put by Neil Robinson in the comments:

Who amongst the public health industry is recognising that the unprofessional and anti scientific behaviour of those few zealots is harming the public trust in their entire message, with all the consequential damages caused by that?

So there you have it: it is time that the naysayers, ANTZs, bossy doctors, risk-averse regulators, prudes and prohibitionists were challenged much harder on the risks they create, the harms they cause and the protection for the cigarette industry that they provide. It wouldn’t be so bad if the risks they created were risks to their health, but they need to be more accountable for the risks they impose on others: it’s not them that bear the consequential harms arising from their misjudgements, ideological posturing and responsibility shirking. Any other examples of the creation of health risks by the public health establishment? In the comments please…