E cigarettes and ending death from tobacco

I want to see an end to the misery, death, disease and disability caused by tobacco. My dad died (a soldier, miner then bus driver) as a result of it, and my grandfather (a farm labourer then miner all his life) too. And there isn’t a day goes by when I don’t miss them both, many years later. People I went to school with (a scottish village full of miners, farm and factory workers) are now disabled by smoking. And my determination only solidified when I read the 2014 report of the surgeon general on smoking, for the 50th anniversary of the Dolland and Hill study, which said smoking was now firmly implicated in Diabetes.

I now believe, equally firmly, that we have enough evidence to use e-cigarettes as part of this battle, and that those who use e-cigarettes are part of a significant consumer-led social movement which we in public health must use for benefit, without disrupting the good which has been done. This is a sea-change in my views. And there are many people – scientists, colleagues and vapers themselves, who have done me the service of making me listen to them. E cigarettes are much, much safer than tobacco cigarettes. And for many, they are more efficacious than over the counter nicotine replacement therapy.

Earlier this week I had the privilege of listening to some quite amazing scientific and policy speakers at the E-cigarette summit 2015 in London. You can find the agenda here http://www.e-cigarette-summit.com , and in a few days you’ll be able to find this year’s presentations alongside those of previous years in the resources section. Professor Ann McNeill proved to be a formidable and good-humoured chair in keeping a completely stuffed programme to time with great grace and aplomb. (And some speakers had things like 30 or even 50 slides for 15 or 20 minute slots.)

Round up notes of the Summit

I took assiduous notes all the way through, only to find James Dunworth, a blogger at the Ashtray Blog did a much better job than my 21 pages of scribble, and to be honest I’ve printed out his -I think accurate and reasonably impartial – blog and put it in my CPD file. You can find it here http://www.ecigarettedirect.co.uk/ashtray-blog/2015/11/e-cig-summit-round-up-the-vape-debate-continues.html

Declaration of interest

Now I don’t vape, and I don’t smoke. I don’t get paid by anyone outside my day job and although my stop smoking team have had some financial support from pharma in the recent past for seminars the County Council’s explicit and written policy is that policy making on tobacco is ours and we will base that on science, not on the commercial interest of any party who wishes to influence us. My concern is what is good or harmful for the citizens who pay my wages.

On disagreeing respectfully

People of widely differing opinions and views spoke, and the audience was one of the most mixed I have seen at a scientific and policy event like this. People who use e-cigarettes, retailers, manufacturers, scientists, policymakers, legislators, regulators and others from across the world. Activists and advocates from all sides sat next to the confused and the undecided. And yes, big tobacco was there too, which was very uncomfortable for me, I must confess. So many people packed into a room with a very tight agenda, all being, on the whole, very much more respectful to one another than I have seen sometimes within the public health community when debating this.

I happen to believe you should be able to disagree vehemently without behaving like a churl to those with whom you disagree. Moreover, resorting to ad hominem attacks just undermines you and sullies for everyone the process of discerning what the science says. And increasingly policymakers feel that those who make ad hominem attacks do so because their arguments and evidence aren’t strong enough to stand up on their own, so it’s fatally counter-productive. Yet it goes on.

I had some good corridor conversations. A number of policymakers who approached me that day had the same dilemma I have just articulated. I also overheard people from completely opposite ends of the spectrum on e-cigarettes say how important this event was. I found that heartening.

What I found somewhat sad was that some of the most vociferous opponents across the globe, and those most prepared to make ad hominem attacks, were absent

My contribution to the event

Anyway, I too was speaking. And for the third time in a fortnight, speaking in the middle of a line up of people whose books and papers I have read assiduously. That’s scary. This week I was in the same day as folk like Robert west and Charlotta Psinger (hello, opposite ends of the scientific position on e-cigarettes.)

I was speaking on the issues and challenges for local Directors of Public Health. You can find my slides here http://www.slideshare.net/jamesgmcmanus/e-cigarettes-challenges-for-local-public-health-systems

My journey of views

Around three years ago I thought e-cigarettes were worrying and probably uncertain as to their safety. This was based on no primary reading but listening to other authority figures who said so. My Head of tobacco control asked me to read the science. So I started. Liz Fisher, my head of tobacco control, is someone whose grasp of the science I fundamentally respect. (She authored a systematic review on smoking in pregnancy for her Master’s despite being told it was ambitious. She did it.) And her instincts on safety and clinical governance are at the pinnacle of those I know anywhere in health care. Her gentle coaxing of me to read the evidence – not try to make my mind up for me – and her own complete change of mind has influenced me.

Two years ago or so I still heeded the views of people that e-cigarettes were uncertain on safety more than those saying they had benefit and we should be extremely cautious. In 2013 I produced a Guardian blog http://www.theguardian.com/local-government-network/2013/nov/19/debate-needed-safety-e-cigarettes-public-health which either looks like someone sitting on the fence or, as I prefer to think of it (perhaps a little charitably) someone calling for debate which is respectful and serious on the science, not on the animus.

Since then I have paid assiduous attention to the science and to the debate, and have reflected on the ethical and policy challenges of this. Eighteen months ago when my mind had changed to move in favour of e-cigarettes I took part in a debate with other public health professionals where I was asked to speak against. A good intellectual exercise to test my thought process in public. My opposing speaker delivered a sound evidence-based presentation with a scintillating assessment of the evidence in favour of using e-cigarettes. I thought I was roundly trounced. I stood up and shed doubt. What was most chilling was that a supposedly evidence-based profession looked like they all voted with me out of fear that e-cigarettes might turn out to be dangerous, ignoring the accumulation of evidence. And when I asked folk afterwards, some confirmed this. “Do no harm” said one. Good motives, but wrong application.

Double standards of evidence and science

Shocked, I pointed out that we didn’t have the level of science on condoms and safer sex for HIV in the 1980s that we have so quickly for the low risk of e-cigarette harms now. I pointed out that we were using the precautionary principle wrongly. I pointed out that we were expecting a much higher standard of evidence on e-cigarettes than we are on other things (a statement I summed up at the 2015 summit by saying that we don’t have RCTs for bridges but on the whole they stay up). I pointed out that we were operating double standards out of an understandable but wrongly applied fear of harming people in how we assessed evidence and science. A few people in discussion later agreed and changed their minds on e-cigarettes. The desire to do no harm needs to realise that doing nothing in this debate can be harmful.

And so, within the last year, I really have changed my mind. I now feel the benefits of e-cigarettes far outweigh the risks, and that they can have significant benefit for public health. There was such a fundamental change in my views that I found it quite unsettling and wondered whether I had really not reasoned correctly. I went back to my great hero, John Henry Newman, and re-read by way of reflecting on my own journey of mind his Apologia pro vita sua where he recounts the “history of his mind and ideas” to convince others, though mostly himself, of his consistency in principle throughout.

Discussion with colleagues then and since confirms in my mind that when you want to do no harm, when the science has been badly reported, when so many of us have little time to do the reading and updating we want to on other issues, and when so many of us don’t know where to start with a fast moving scientific field, the things which mitigate to keep your views where they are outweigh the resources you can find easily to change. I know that’s not acceptable, but it’s whats going on. Trusting that our instincts to be evidence based can enable us to make sense of this can be difficult when the science and the landscape is fast moving, and the debate often so fractious.

My views now

As with all things, I will keep chasing the evidence, and will keep our positions under review and if it turns out that there are likely to be worrying harms, we will act. But I do this with all areas of our public health responsibility, why wouldn’t I? E-cigarettes in this respect are no different. Keep an eye on the evidence as it changes, and develop and build programmes accordingly.

But it seems to me that we have enough of an accumulation of evidence that e-cigarettes are so much safer than tobacco cigarettes, even if we only discuss the levels of emissions of chemicals, that not working with e-cigarettes is to expose people to potentially avoidable harm, and that this is unethical. I feel ethically compelled to find a way of working with e-cigarettes as a public health tool. And the fact that some public health debate has made people – wrongly as the consensus statement says – feel e-cigarettes may even be more harmful than tobacco is something we ought to find shocking and chilling.

I could go on for ever about the things that have changed my mind, but I think we are seeing a paradigm shift happen in the use of tobacco and nicotine with e-cigarettes. This is a consumer led initiative, and this has significant public health potential. In the briefest of summaries here is some of my thinking :

The Precautionary Principle- we have applied this wrongly and too strongly in resisting e cigarettes. It can cut both ways. One interesting read on this is here http://leidenlawblog.nl/articles/an-application-of-the-precautionary-principle-in-e-cigarette-ban Clive Bates has produced an interesting note on the precautionary principle here http://www.clivebates.com/?p=1691 The precautionary principle does not, for me, entail a ban until absolute certainty of safety. We’re not asking for this for coffee, or alcohol, where the evidence of harm is stronger than nicotine or e-cigarettes. We’re in danger of double standards here (see point 6 below.) We seem to want safe, not safer. We don’t want that with sex in the age of HIV. What legitimises us demanding it here? Rights, choice and equity – our citizens have rights to expect our help and to do this equitably. Respecting their views is important, and we have to work with people where they are, not where we want them to be. That’s the ethos behind harm reduction. Surely if we are engaged actively with this movement we can steer people away from the harm of tobacco and, if it ever happened that e-cigarettes were to have worrying harms attached to them – we could be in there early and react much more quickly. The Scientific Evidence is that these are much safer than tobacco and that there is some extremely bad science on formaldehyde and other constituents of e-cigarettes being used sloppily to justify restrictions. The ashtray blog’s summary of the summit does a fairly good job of summarising these issues presented at the 2015 summit. The gateway effect – well, as we heard repeatedly at the Summit, this is just not happening with any force or seriousness. A consensus from very different speakers on this and very different sources of data outside the summit makes this clear. “E cigarettes will contribute to renormalization of smoking” – there is no real evidence of this from any economy. Apart from anything else, the conception that a device looking more like Dr Who’s electronic screwdriver than a cigarette might renormalize tobacco is ludicrous beyond words and based on poor logic. Voigt’s 2015 paper seems to me to pull apart the uneasy logic behind renormalization. http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2015.302764 Nicotine and harm – the evidence on nicotine being harmful seems clear on first trimester foetal development patchy on one or two other areas, and largely absent anywhere else. In many areas, evidence of nicotine harm in doses delivered by cigarettes or e-cigarettes is just not there. (Many lab studies use massive nicotine doses way beyond what we’d have in reality.) The possibility of uncovering harm in 20 years cannot justify inaction now when the evidence for much greater harm from tobacco is scientifically unassailable. I know absence of evidence is not evidence of absence but we need to consider whether we are against nicotine caused harm (still paucity of evidence) or nicotine addiction per se. If nicotine addiction is a new public health target then someone please be honest and say so. We seem to adopt harm reduction in other areas, such as opiate addiction. Why are we content to be making an assumed and not explicitly conceptualised perfect which is not evidence-based (nicotine abstinence) the enemy of the good (reduce death, disability and disease from tobacco) in this case? That’s double standards. Some who say people should be able to choose cannabis freely and legally still want to prohibit nicotine, despite the evidence of harm for cannabis (and indeed alcohol) being a good deal stronger than that for nicotine, yet still the subject of fierce debate. The recent British consensus statement on e-cigarettes was an attempt to speak clearly that e cigarettes are less harmful than tobacco and put some stakes in the shifting sands of the science, consumer activity, policy and ethical debate on this. You can read it here https://www.gov.uk/government/news/e-cigarettes-an-emerging-public-health-consensus .

A bit of humility 1: Don’t over medicalise

We in public health are late to the table on this, and sometimes expect people just to shove over and give us respect when we have not really earned it and haven’t really listened much either. Our presence, intended to seize on the public health benefits of e-cigarettes which helping monitor for safety and reduction in harm from them is intended to be beneficial to our populations. But we could disrupt and have unintended consequences. Some countries have taken action which perversely helps big tobacco keep people on cigarettes.

E cigarettes are a consumer choice-led movement, and indeed safety of devices has been responsive from those manufacturers who take their markets seriously, and many specialist retailers see themselves as having an ethical duty to help consumers (it’s good for business) much more so than the lowest common denominator stuff available in, for example, most newsagents. Most pharmacists and newsagents don’t seem to know what they are selling. That isn’t an argument against these devices, it’s an argument for responsible and knowledgeable retailers of quality.

But if we turn these things too much into a medical tool, it could backfire. We could restrict access to what is really a consumer product, and which seems to be helping people away from tobacco largely without public health and the public purse getting involved.

The challenge for us is using them in a way which gets public health benefit, and clinical benefit, without destroying the consumer choice which has done more than anything or anyone to move people off tobacco and onto these devices.

Public Health has no pre-eminence in this debate. It should come to serve the public good, and discern how in doing so it can avoid disrupting the existing benefits created by the market. We need to learn the lessons from activist and community led work on HIV prevention in the 1980s, lest we set progress back.

A bit of humility 2: Scientific Locus

The old concept of locus standi is something we need to look at here. Who has a place from which they are entitled, morally, scientifically or legally, to speak on this issue and command our attention? It seems to me that those scientists actually doing research, and those people who use e-cigarettes, and those people whom governments have charged with properly and duly discerning the science and the evidence, are at the top of the tree here.

The rest of us need to speak with some humility and must do so in a spirit of reading and listening to all sides. A key thing about this debate is that there are many wading in who have no track record of primary or secondary research in this (such as me, for example). And the number of studies I have read where people make conclusions which simply are not justified by their methods is worrying.

So Public Health England in my view is the authentic voice in this of the Public Health system in England because they have the legal mandate to advise. They commissioned scientists who have done work on this and whose expertise this area is and those commissioned have produced a careful analysis subject to due scrutiny and review. The distasteful response of some to attack the reputations of those involved rather than try to critique the science is shameful and unworthy. And the mooted “peer reviews” by several actors in this debate of the Public Health England review looks to me like a failure to understand locus. It is not the job of any individual or agency to mark the homework of their scientific betters. I remember two public health people asking me at the summit about whether the PHE report needed peer reviewing before they trusted it. “What would you do with anything else?” I asked. “read it and critically appraise it” came the response. “That’s what we do with everything, right?” I said. We don’t need special additional scrutiny here, just good public health science and method.

A bit of humility 3: Sex, cigs and entrenched views

In answer to a question I recall commenting that this felt like the debate on the Church of England and same sex relationships all over again. That got a laugh, and while it does sound ridiculous, there is a serious point here. And as a Catholic I can’t exactly throw stones at the Anglicans while this debate rages in my own Church. The theological case for same sex relationships being an acceptable Christian way of living was first made in English by Derek Bailey in his1948 volume Homosexuality and the Western Christian Tradition. John J McNeill’s great 1977 book for Catholics, John Boswell’s first book (1982) and then two books by C of E Bishops (1982 and 1989) continued this and since then we have had a host of theological, biblical and other studies which convince me that being Christian and LGBT is possible. Yet many cling to a view that scripture condemns same-sex love. Several papers – psychological and theological since 1982 – have argued eloquently that the use of biblical authority texts to proclaim homosexuality is wrong all rely on supporting an emotional, visceral reaction to this rather than reason. Scripture is used as a weapon to protect entrenched views, and people read the Bible to justify their views. They don’t allow the Bible to “read” them. That’s wrong in my view, but it’s not homophobia, it is deep seated, emotionally held, and may well be utterly sincere. Sexuality for many of us Christians will continue to be a hot and painful debate issue for decades to come.

And it seems to me something very similar goes on with e cigarettes. There are some who deeply, sincerely have a revulsion to e-cigarettes because they may fear, genuinely, that what has been done on denormalizing tobacco will be undone by e-cigarettes. Or they may look back on their careers and see that this sea change undermines many certainties they have. This is a painful place to be. I was somewhere not far from there on e-cigarettes not that long ago. But while I understand it, it doesn’t mean I am content to leave people there. We must move forward. We cannot use poor science on formaldehyde or particles or distortion of the precautionary principle as a justification for not moving forward. Public Health must be at the sharp end. There is often a delay between evidence and practice at the sharp end, as I remember from the early days of HIV.

Equally there are others for whom the war on tobacco killing people has moved on to be a war on nicotine, or a war on the tobacco manufacturers rather than on tobacco and its consequences.

At the summit I asked one such person why it would not be a good thing if big tobacco stopped making tobacco products tomorrow and made tea-towels instead. The response was “you obviously don’t understand…they are evil.” Really?

We continue to see some authors whose arguments have been roundly refuted repeat, ever more shrilly, their arguments in print on e-cigarettes. There is an ethical duty to speak if we genuinely believe e cigarettes to be harmful and dangerous. But there is an ethical duty too to hear the evidence which refutes us, and keep our position under review. Had we conducted our debate with humility; prudently and carefully on the evidence, would we really have needed the British consensus statement?

And so, we are left with a choice: refuse to move and see people harmed avoidably. Or recognise and affirm what can be clearly recognised as beneficial, act when the evidence shows harm, and work as best we can, constantly discerning what the good is, while things are developing. Surely this is where public health skills, brought to serve the good of our citizens, were meant to be? Serve, discern and protect.