When you do what you did, you get what you got

When the World Health Organization (WHO) talks about nicotine and tobacco, the world listens. And, unfortunately, what they hear — at least on the subject of vapor products — is just awful. The public health arm of the United Nations has consistently called for strict regulation and even prohibition of e-cigarettes. The WHO’s Framework Convention on Tobacco Control (FCTC), meets in Delhi, India for its seventh Conference of the Parties (COP7) November 7-12. The FCTC convenes every two years to discuss strategies and priorities for tobacco and nicotine policy and regulation among its signatories.

Let’s just keep trying more of what we’ve been doing

In advance of the conference, the FCTC issued a report on e-cigarettes that will be the nexus of discussion on vapor products policy among the member countries. The report is a prohibitionist’s dream of cherry-picked science, and an implicit call for bans until the products can be proven “safe.” Since that’s not possible — at least not for decades — the WHO is apparently okay letting millions die preventable deaths every year while it debates the absolute safety of alternatives to smoking. Let’s just keep trying more of what we’ve been doing, they say. Maybe the smoking problem will fix itself. Hey, maybe we can raise taxes again! The FCTC’s persistent anti-harm reduction stance on nicotine products is at odds with its own charter. But rarely does anyone complain, because the general attitude in public health and government circles is that tobacco is bad, everyone knows it’s bad, and therefore smokers essentially get what they deserve. Quit or die, they say. And six million smokers die every year.

The British School

But the United Kingdom is flipping that narrative. A group of tobacco and addiction researchers who are also harm reduction proponents have done amazing work over the last couple years to change the British health establishment’s views on vaping, and to challenge quit-or-die ideologues around the world. The “British school” has shaken things up considerably in the staid tobacco control world. First there was the 2015 report, “E-cigarettes: an evidence update” from Public Health England (PHE), which concluded that vaping is at least 95 percent safer than smoking. Then, earlier this year, the Royal College of Physicians (RCP) published its comprehensive 200-page “Nicotine without smoke: Tobacco harm reduction.” Both reports earned worldwide attention, and forced a lot of tobacco control dinosaurs to scramble to explain their stodgy anti-everything stances.

Challenging their conclusions requires truly focused ignorance

The researchers involved in these efforts — John Britton, Ann McNeill, Peter Hajek, and Hayden McRobbie, among others — are top-notch scientists. They are the experts in tobacco, smoking, and nicotine use and addiction. No one anywhere can look at these reports and claim the work is slipshod, biased, or lacking in detail. Challenging their conclusions requires truly focused ignorance. Now add another document to the library. Researchers at the UK Centre for Tobacco & Alcohol Studies (UKCTAS) have just issued a scathing response to the WHO’s pre-COP7 e-cigarette report. The UKCTAS commentary takes apart the WHO document point by point, exposes every flaw, and shows it as the political manifesto that it is. The authors of the response were all contributors to either the PHE report or the RCP one, or both. Prof. John Britton of the University of Nottingham is also the chair of the RCP’s Tobacco Advisory Group. Ilze Bogdanovica is a Cancer Research UK Career Development Fellow at the University of Nottingham. Ann McNeill is a professor of tobacco addiction at King’s College London. Linda Bauld is a health policy professor at the University of Stirling, and also works with Cancer Research UK.

British scientists to FCTC: pay attention!

The UKCTAS authors use the language of the WHO report in their responses. So prepare to be assaulted by “ENDS” (Electronic Nicotine Delivery Systems), and even the utterly ridiculous “ENNDS” (you guessed it, Electronic Non-Nicotine Delivery Systems).

Vapor is positioned as a threat rather than an opportunity

“Overall, the WHO report does not correctly position ENDS [Electronic Nicotine Delivery Systems] primarily as an alternative to smoking and instead focuses excessively on risks of ENDS use without adequately recognising the deep reductions in health risks when a smoker switches to ENDS.”

Failure to quantify risk

“In terms of toxicology, the discussion is naïve and places excessive emphasis on negligible risks arising from very low exposures. In toxicology, the presence of a potentially harmful agent does not necessarily establish a material risk.”

Inadequate comparisons with smoking

“The WHO paper does not systematically make meaningful comparisons with exposures arising from inhaling tobacco smoke or refer to other useful comparators such as occupational exposure limits. However, data from around the world shows that almost all ENDS users are smokers, ex-smokers or would-be smokers.”

Misrepresenting second hand risks

“The claim that ENDS have the “potential to lead to adverse health effects” in bystanders does not reflect the science behind the cited source unless ‘potential’ is taken to mean any exposure, no matter how trivial. Again, the issue is not the presence of particular chemicals, but the magnitude of exposure.”

Downplaying the evidence that vapor helps smokers quit

“The WHO paper does not properly assess the role that ENDS play in quitting smoking and uncritically repeats a number of methodological errors found in the literature. Taking the totality of evidence including controlled trials, observational studies, changes in population smoking and ENDS use, the experience of nicotine replacement therapy, and widely reported user experience, there is confidence that ENDS are helping many smokers to quit smoking and not having negative effects like renormalising smoking, reducing quit rates or creating gateway effects.”

Vapor products marketing can be anti-smoking advertising

“The vast majority of ENDS marketing is truthful promotion of a low-risk alternative to smoking and targeted at adult smokers. The evidence cited by WHO has been misrepresented and does not make the case for any systematic malpractice by ENDS vendors.”

Flavors are essential to the appeal of vapor as alternative to smoking

“The section on ‘product characteristics’ attempts to demonstrate a problem with flavours appealing to teenagers. In fact, flavours are integral to the appeal of ENDS to adults as an alternative to smoking. The citations are selective and findings misinterpreted and do not support this claim.”

Mischaracterization of the vapor market and role of Big Tobacco

“The WHO paper misinterprets the ENDS market, makes misleading and unreferenced statements about the role of transnational tobacco companies in the market and is not grounded in an understanding of how competitive markets function. WHO’s report fails to acknowledge the threat of disruptive technology such as ENDS to the commercial viability of the traditional cigarette business. Ironically, the only references given to published papers point out how regulations, such as those favoured by WHO, actually help the cigarette trade. WHO should be aware of the danger that its policy proposals may provide the traditional tobacco industry with a twin advantage: (1) slowing down the disruption of the cigarette market by ENDS; (2) shaping the ENDS market to suit the ENDS business model favoured by the tobacco industry.”

Unjustified support for prohibition

“In the discussion of policy options, the opening paragraph for each policy set implicitly endorses ENDS prohibition. It does this by stating that “Parties that have not banned the importation, sale, and distribution of ENDS/ENNDS may consider the following options”. Prohibition is one regulatory option among many that ought to be discussed on its own merits, not taken as a default. The merits of prohibition are exceedingly poor given the pervasive availability of cigarettes in all jurisdictions.”

Policy proposals made with no supporting policy analysis

“Numerous policies are proposed without any supporting evidence for their effectiveness or cost-effectiveness. Any policy proposal should be subject to evidence-based justification, options appraisal and analysis of trade-offs or distributional effects, and impact assessment.”

No assessment of unintended consequences

“Almost every policy listed in the WHO’s paper could easily have the effect of protecting the incumbent cigarette trade, promoting smoking rather than vaping, and lead to increases in non-communicable diseases. It is very likely that widespread uptake of WHO’s policy proposal would ‘reduce harm reduction’ and therefore increase harm.”

Transparency and quality

“The WHO report has been made available without the four supporting papers upon which it is supposed to be based. These papers are still undergoing revision during peer review. This is poor scientific practice and does not provide a reliable basis for policy advice.”

Will the WHO care?

Will the UKCTAS response force the FCTC to modify its stance on low-risk nicotine products? Or will they do with this document what the FDA did with the PHE report — ignore it? They won’t have an easy time of it if they try. There will be a focused campaign by consumer groups to push the delegates at COP7 to acknowledge and address the issues raised in the UKCTAS response.

Vapers on Twitter should watch the official COP7 hashtag #COP7FCTC. Expect to see the visible social media face of the FCTC turn red when vapers and harm reduction advocates shame it by calling out the hypocrisy of its anti-health prohibitionist mindset. Groups like the New Nicotine Alliance and INNCO are poised to keep the pressure on the COP7 delegates before, during, and after the conference. Most WHO anti-tobacco zealots don’t understand nicotine use, don’t trust anything that looks like smoking, and probably have never even spoken to a smoker. This response by UKCTAS directly challenges their comfortable ignorance, and demands that harm reduction be part of the FCTC’s anti-smoking arsenal. Will they listen?