In the 1970s, a group of students in South Africa were planning a campaign against tobacco. I was one of them. We paid a visit to Rembrandt, the country’s leading cigarette manufacturer, to hear their side of the story.
They showed us shiny floors, introduced us to well-paid employees of all races — a rarity in apartheid South Africa — and proudly described their extensive support for the arts, culture and the environment. We replied that this was great, but it failed to address the core issue: their products killed half their regular users and harmed many more.
So the campaign went ahead. For me, it was the start of decades of battles with tobacco companies that led to strong regulations in South Africa — and culminated in the World Health Organisation (WHO) Framework Convention on Tobacco Control, now in effect in almost 180 countries.
Along the way, I learnt to distrust every move by tobacco companies and felt fully justified when an inquiry, supported by WHO and the World Bank, declared: ‘Evidence… reveals that tobacco companies have operated for many years with the deliberate purpose of subverting the efforts of WHO to control tobacco use. The attempted subversion has been elaborate, well financed, and usually invisible.’
It’s not surprising that most people in public health strongly endorse the view of Dr Neil Schluger, a lung specialist and professor of medicine at Columbia University, that ‘If there ever was an industry that does not deserve the benefit of the doubt when it comes to protecting or promoting the public’s health, it is the tobacco industry.’ The industry’s deceptions have included the development of low-tar products and a crafty message suggesting that they did less harm. Years after their launch, however, research showed that low-tar cigarettes had exactly the opposite effect.
Now we have electronic cigarettes. Is this the latest ruse, or is it really an innovation we should welcome?
Let’s review the appalling statistics. There are about 1.3 billion smokers in the world and roughly six million smoking-related deaths every year. In the United Kingdom alone, smoking causes 80,000 deaths. That’s 18 per cent of all deaths. What’s more, for every death there are 20 smokers suffering from tobacco-related diseases, resulting in 450,000 hospital admissions each year. No other single cause of death and disease can so easily be prevented.
The WHO framework convention stresses the value of government-led measures: increasing excise taxes, banning all marketing and advertising, and promoting smoke-free workplaces. Early in its development, we invited tobacco company scientists to provide evidence that their harm-reduction measures were real and not merely marketing ploys. Their responses were unconvincing.
At the same time, the first public evidence emerged that, for decades, tobacco companies had a sophisticated understanding of the role of nicotine. But they had failed to act on this knowledge and separate the harm caused by combusted tobacco from the ‘pleasure’ some people obtain from nicotine.
Let’s take a quick look at another tobacco product — one that’s never caught on in the UK. Snus is smokeless tobacco in a little packet that Swedes tuck against their gum in order to get a nicotine buzz. For many years, the increased use of snus versus regular tobacco has been a major factor in Swedish men having the lowest death rate in the European Union.
Indeed, death rates from all causes among European men are about 2.5 times higher than among Swedish men — thanks, in part, to snus. Also, as snus use has increased, smoking has decreased. Snus was banned in all EU countries except Sweden (and Norway, which isn’t in the EU). In Finland, the ban slowed down the drop in smoking. In Norway, by contrast, snus consumption by adults rose from 4 per cent in 1985 to 28 per cent in 2012 — and overall tobacco use fell by 20 per cent.
What drove these changes? Tobacco advertising (including for snus) has long been banned in all three countries. Public health authorities speak out against all forms of tobacco, including snus. Nonetheless, consumers, influenced by price and information from social networks, have increased their use of snus.
So what has this to do with the emerging e-cigarette debate?
We’ve seen that snus is banned in most of Europe despite overwhelming evidence that it is harm-reducing. And now e-cigs and other innovative ways of delivering nicotine without the dangers created by burning tobacco face the same challenge.
Traditionalists demand more of the same policies that have significantly reduced tobacco use: excise taxes, full implementation of smoke-free workplaces and more effective anti-smoking advertising. Long-term projections say this would reduce smoking in the United States from the current 20 per cent to 10 per cent by 2030. That’s welcome — but it still leaves millions of smokers at risk.
The call for higher excise taxes ignores rising concerns about their regressive impact on poorer and more-addicted smokers. It also ignores advances in the genetics of nicotine use, suggesting that half of all smokers may not respond to tax increases because of their need for nicotine. In other words, our one-size-fits-all approach to tobacco control is doomed to fail.
Action on Smoking and Health estimates that 2.1 million British adults currently use e-cigs. About one third are former smokers, and two thirds are still smokers. Meanwhile, regular use of e-cigarettes by children and adolescents is confined almost entirely to current and former smokers. Users claim that e-cigs help them stop smoking entirely (38 per cent) or reduce the amount they smoke (25 per cent). Robert West, professor of health psychology at University College London, reports that e-cig use by never-smokers is negligible and similar to that of nicotine-replacement therapy (NRT).
In recent years, the increase in the popularity of e-cigs has more than offset a decrease in NRT use. Successful attempts to quit smoking, although escalating, are still low, at between 5 and 7 per cent. E-cigs could play a major role in helping those smokers most addicted to nicotine, who are shifting in increasing numbers from NRT products to ‘vaping’ as their means of quitting the tobacco habit.
Safety concerns were addressed recently. Two analyses reviewed toxicological, laboratory and clinical research on the potential risks. They concluded that e-cigs are by far less harmful than smoking, and that ‘significant health benefits are expected in smokers who switch from tobacco to e-cigs’. Yet governments and the WHO remain unconvinced about the benefits of e-cigs. There is deep distrust of tobacco companies. This is borne out by article 5.3 of the framework convention, which requires that ‘in setting and implementing their public health policies with respect to tobacco control, parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law’ — i.e., avoid any interaction with tobacco companies. But this policy is impossible to implement in countries where democratic law-making processes require interaction with all stakeholders, or where the government owns a tobacco company.
Moreover, it limits the potential to make use of scientific discoveries by tobacco companies. At a WHO tobacco control conference last October, governments stressed the need to protect tobacco-control activities from all commercial and other interests. That effectively means not talking to researchers developing new and safer products. They also wanted governments to consider prohibiting or regulating e-cigs as tobacco products — which would be a huge boost to the deadly status quo.
The US Food and Drug Administration (FDA) has already announced its intention to regulate e-cigs as tobacco products. About $2.2 billion was spent on e-cigs in America last year, exceeding the amount spent on NRT but still representing a small part of the $85 billion cigarette market.
At the same time, however, the FDA seems to favour a transition away from lethal combustible products. Mitch Zeller, director of its Centre for Tobacco Products, wants us to look at nicotine differently. People ‘smoke for nicotine but die from tar’, he says, and new products represent a public health opportunity.
The FDA’s measured approach is in contrast to the continued unscientific approach of the US Centres for Disease Control and Prevention, whose director Dr Tom Frieden stated last year that ‘many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes’. They have yet to produce evidence that this is the case. In November, Penny Woods from the British Lung Foundation said ‘[new] data should again alleviate the fears expressed by some over an e-cig gateway effect’. Let’s spell this out. Unsupported statements are accepted as truth by policymakers and are used as the basis for stringent regulation of e-cigs in many jurisdictions.
This may well end up causing more public health harm than good. The benefits of e-cigs in helping smokers quit or cut down should be weighed against the danger of either recruiting new smokers or creating e-cig addicts. So far, there is no evidence that either of these things is happening. Studies in both Britain and America suggest that, as e-cig use increases, youth cigarette consumption declines.
Why are we in this position? One reason is that governments have become addicted to tobacco excise tax and may fear that, as e-cigs take off, they will lose a valuable source of revenue. Many leading NGOs and academics exert strong influence at WHO, within governments, in the media and among the general public. In the past, they helped bring tobacco control out of the shadows and into the mainstream of health policy. Now, alas, their intransigence threatens more profound progress.
We need clear, unambiguous messages to smokers about the safety and benefits of e-cigs. An example is the March 2014 statement on the Royal College of Physicians website that ‘the main benefit of e-cigarettes is that they provide inhalable nicotine in a formulation that mimics the behavioural components of smoking but has relatively little risk… Switching completely from tobacco to e-cigarettes achieves much the same in health terms as does quitting smoking and all nicotine use completely. Furthermore… risks associated with passive exposure to e-cigarette vapour are far less than those associated with passive exposure to tobacco smoke.’
If influential health officials were to make these points repeatedly, public sentiment towards e-cigs would shift quickly. And this could be done at the same time as strengthening anti-smoking measures.
We should praise ‘good’ e-cig companies who commit to safety, to avoiding youth marketing, and to making smoking obsolete. They need to be explicit about their long-term plans. Are they seriously committed to harm reduction, or introducing new products simply to delay progress and confuse policymakers, as many in public health believe?
From my meetings with major tobacco companies, it’s clear that they are hedging their bets. Some of them have indicated, in private, a long-term goal of moving out of manufacturing harmful tobacco products — but these statements are not enough to inspire trust. Tobacco companies’ intention to change must be stated publicly and backed by action.
Other market sectors need to adapt to the reality of e-cigs as a force for good. Retailers should voluntarily withdraw cigarettes from stores, or at least reduce their prominence, in favour of e-cigs and NRTs. CVS Health has yet to offer e-cigs, despite the fact that they work better than pharmaceutical products. Life insurers still treat e-cig users as regular smokers when they calculate premiums. This is short-sighted and misses a golden opportunity to spell out the benefits of quitting smoking and the positive impact of switching to e-cigs on people’s longevity.
At the moment, it’s estimated that there will be a billion tobacco-related deaths before 2100. That is a dreadful prospect. E-cigs and other nicotine-delivery devices such as vaping pipes offer us the chance to reduce that total. All of us involved in tobacco control need to keep that prize in mind as we redouble efforts to make up for 50 years of ignoring the simple reality that smoking kills and nicotine does not.
A toxic legacy
Evidence that the tobacco companies knew of the importance of nicotine to smokers 50 years ago:
— ‘Nicotine is addictive. We are, then, in the business of selling nicotine, an addictive drug effective in the release of stress mechanisms.’ 17 July 1963, Brown & Williamson general counsel/vice president Addison Yeaman.
— ‘It is my conviction that nicotine … both helps the body to resist external stress and also can as a result show a pronounced tranquillising effect. … under modern conditions of life people find that they cannot depend just on their subconscious reactions to meet the various environmental strains with which they are confronted. … smoking has considerable psychological advantages and a built-in control against excessive absorption. It is almost impossible to take an overdose of nicotine in the way it is only too easy to do with sleeping pills.’ 29 May 1962, BAT memo ‘The Smoking and Health Problem’