Public interest consultant and former United Kingdom government advisor Clive Bates has accused policymakers and anti-tobacco lobbyists of ‘insanely’ turning their big guns on harm-reducing nicotine-related products instead of allowing market forces to edge out far more dangerous combustible tobacco products, writes MedicalBrief.
This was the key message from the former director of Action and Smoking and Health during a well-attended webinar titled “Vaping and Tobacco Harm Reduction”, writes MedicalBrief’s Chris Bateman. The webinar was hosted by Drug Science, a UK-based drugs advisory committee, and held on 10 February 2021.
Bates – founder of Counterfactual Consulting, a public interest consulting and analytical advocacy outfit – said 96,000 people died prematurely from smoking every year in the UK. This way outstripped deaths from obesity, alcohol, road accidents, drug misuse and HIV, which unlike smoking, generally killed people earlier on in life.
On the other hand, all available evidence suggested that deaths linked to e-cigarettes alone were unlikely to exceed 5% of those associated with smoked tobacco products.
Yet the UK put a ‘whacking great tax’ on cigarettes, compounding health inequities because smoking prevalence was highest in the most disadvantaged and vulnerable groups – a pattern repeated worldwide.
“Cigarette smoking prevalence goes up for people with depression (40%), those with substance abuse disorder (88%), psychosis (62%) and those who live in disadvantaged conditions such as the homeless (57% to 82%) and prisons (80%),” he said. The median harm profile of a lifelong smoker was that they lost 10 years of life between the ages of 73 and 83.
Smoking prevalence in England was 14%, but double that in deprived areas, with prevalence increasing among the jobless and poorly educated.
Smoke for nicotine, die from tar
Bates said nicotine on its own was a “fairly mild and innocuous” drug, and was not what caused the harm in smoking. People smoked for the nicotine but died from the tar – and the related toxic substances released by combustion. These caused cancer, heart disease and a myriad other associated illnesses.
If governments tackled their own hypocrisy by supporting far less harmful products – that is, alternative nicotine delivery systems – to edge out combustible tobacco, there was potential to disrupt the 120-year dominance of cigarettes.
He cited the ‘proof of concept’ of snus – tea bag-like tobacco pouches placed between the lip and gum to absorb nicotine. Its predominant use in Sweden had dropped daily smoking prevalence to 5%, compared to 23% in Europe where Snus was banned. Sweden’s all-cause mortality rate under the age of 30 was now the lowest in Europe.
When it came to vaping and ‘heat not burn’ products, biomarkers – traces of toxins in blood, urine and saliva – were far lower in vapers than in cigarette smokers.
Heat not burn devices, also called heated tobacco products, contain tobacco leaves that produce nicotine when heated. They are different to e-cigarette or vaping devices, which generally use chemical liquids (rather than tobacco) that may contain nicotine or flavourings.
Bates said the heated tobacco products experience was closer to smoking than e-cigarettes, with an aromatic, strong nicotine dose. Research has shown that heat not burn devices cause far less harm than ordinary cigarettes, although they do produce more toxins than e-cigarettes.
The advantage of heat not burn devices – such as IQOS and Eclipse, which are permitted for sale in the United States – is that they are less harmful than cigarettes because there is no combustion, and they can reach cigarette smokers who find e-cigarettes unsatisfactory.
Heated tobacco products have been “fantastically successful in Japan where there’s been a 40% reduction in cigarette sales over the past three years. It’s had a cataclysmic impact on the cigarette trade, which will have huge health benefits,” he added.
Governments missing the boat
Many strong economies regulated strongly and taxed harmful combustible tobacco products but failed to encourage the use of less risky alternatives.
“Yes, smoking is the problem, but we now have four categories of low-risk alternatives with good evidence of reduced harm and population health benefits. The evidence suggests people use them as alternatives, not in addition to smoking.
“Long term, the market will ultimately transform, with combustion going and nicotine staying. Risk-proportionate regulation is the way to engineer that,” he stressed.
“Unfortunately,” Bates added, “a lot of people reject that strategy and are going for nicotine as the new front in the war on drugs”.
He said Sweden’s huge success with snus only highlighted “the most insane regulation of all time, where every other European country bans snus, even though it delivers the best tobacco and health outcomes – that’s a special level of insanity,” he added.
Smoke among Swedish girls aged 14-16 had plummeted from 17% in 2009 to 1% last year. “An entire generation is going to grow up there without smoking in any significant numbers,’ he said.
In the United States a snus-like pharmaceutical product was already “eating through the smokeless tobacco market”.
Tell it like it is
Bates said the 2020 EVALI – E-cigarette or Vaping product use Associated Lung Injury – tragedy that unfolded in the United States last year, had been globally misrepresented and had dramatically set back the harm reduction cause.
While EVALI deaths were blamed on e-cigarettes generally, in fact they were caused by a Vitamin E acetate added to illegal products make expensive cannabis-based liquid dilutant go further. The unscrupulous criminal elements who did this stopped immediately the findings were made public – as did the deaths.
“It was blown up into a worldwide problem for e-cigarettes and affected risk perception which affected behaviour, slowing the rate at which they were eating into the cigarette market and stopping people from switching products.”
Bates said random controlled trials concluded that e-cigarettes helped people to quit smoking but failed to answer the ‘real world’ questions requiring the quantification of people who successful switched – and the reasons why.
“Appeal and user choice make a huge difference in the real world. It’s all about the value proposition, which tobacco control degrades,” he explained.
Regulators did this by forcing the use of plain packaging, hiking e-cigarette prices, banning their use in certain places, mounting anti-vaping campaigns and generally making non-combustible alternatives less appealing and appearing equally harmful.
“However, in tobacco harm reduction, you take the alternative value proposition and enhance it – by using, for example, lower taxes, comparative risk warnings and attractive packaging.”
Bates added unequivocally: “I don’t mind if a company makes money in shifting people from high risk to low risk. But it’s different if the low-risk products are outlawed and most of the harm is done through collateral damage associated with illegality, the criminal supply chain, lack of regulation and impurities.”
“They need to be able to advertise and let people know about their products, to counter the tobacco oligopoly which has sown up the supermarkets and corner stores,” he said.
“Vaping and Tobacco Harm Reduction” webinar with Clive Bates
The Counterfactual website (Open access)
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