The Washington Post has published a letter from the vice chair of the American Thoracic Society’s Tobacco Action Committee attacking the FDA for its more neutral position on new nicotine technologies, accusing the agency of promoting a switch from one addiction to another, underlining an ideological trope that lies at the heart of much of the response from many national and international so-called ‘health’ agencies.
In the letter highlighted by Dr Michael Siegel, which should have been headlined ‘What planet is she on? Oh right’. Dr Enid Neptune wrote: "As a physician who treats patients devastated by tobacco-caused lung disease, I was concerned by the Aug. 5 editorial “Breaking nicotine’s grip” which embraced Food and Drug Administration Commissioner Scott Gottlieb’s plan for regulating tobacco products. The commissioner seems unconcerned about switching one form of nicotine addiction with another. Nicotine in any form is bad for your health, adversely affecting neurological and cardiovascular systems and reproductive health. Evidence shows that nicotine can be a gateway drug. ... The FDA’s job is to protect youths from all types of tobacco and nicotine addiction, not to negotiate which types of nicotine addiction it will allow."
Dr Siegel goes on to comment, “Opiates in any form are bad for your health, adversely affecting neurological and cardiovascular systems and reproductive health. Evidence shows that opiates can be a gateway drug and there is a great risk of overdose with any opiate. The job of physicians is to protect people from all types of opiate addiction, not to negotiate which types of opiate addiction they will allow. OK - I was being facetious”. Except this is very much the view of a substantial slice of those working in the drug addiction treatment field across the world together with national governments, politicians, anti-drug campaign groups and just about anybody who refutes the idea that opiate substitute therapy is a valid harm reduction intervention which incidentally is backed by a stack of international clinical evidence.
And there are plenty of examples from the drugs world where officialdom will never let the evidence get in the way of a preconceived morally-driven political position. Back in 1950, the UN sent a commission of enquiry to Peru to study the coca leaf with the sole intention of demonising the plant in order to justify increasing international controls on cocaine. In 1971 the French delegate to the Commission on Narcotic Drugs (CND) introduced a resolution trotting out all the myths of cannabis use and was keen for the CND to commission research that would prove his claims. The British delegate (to his credit) said he wasn’t prepared to vote on a resolution based on evidence he was expected to accept on faith. In 1995, under pressure from the USA, the WHO had a report supressed which said that moderate/occasional use of cocaine did not pose a significant health risk. And again in 1998, the WHO was strong-armed by the Americans (its major donor) into supressing a report concluding that cannabis was no more dangerous than alcohol or tobacco.
As yet, there have been no revelations about suppressed international reports confirming the relative health benefits of alternative nicotine delivery systems. In this era of mass, varied and rapid global communications, that would probably be quite hard to pull off. What we have instead is solid science being rubbished, science of dodgy provenance being passed off as ‘evidence’, and generally a climate of public misinformation and a denial of the pleasures of nicotine replaced by an obsession with nicotine ‘addiction’ conjuring up images of users dribbling in some derelict building having robbed their grannies for a hit. And all flown under the convenient but frankly undeniable banner of ‘don’t trust Big Tobacco”.
Those of us of a certain vintage will remember the advertising slogans aimed at promoting cigarette take-up especially among young people. In the UK, I recall, ‘You’re never alone with a Strand’ (no, because eventually you’ll be in a hospital bed surrounded by doctors and nurses); “Consulate; cool as a mountain stream” and generally the aspirational sophistication of advertising and packaging promising a life of fast cars and faster women if only you smoked one of the upmarket brands like Dunhill, Rothmans or the gold-wrapped Benson & Hedges. Not all brands qualified for glossy PR treatment; Players No 6, Woodbines and Craven A, for example, were only for those aspiring to hold onto their lungs until they got their pension.
In the West, all that promotional activity has been swept away. But not so in countries like India. There has been media coverage of the tactics being used by PMI to engage young people including attractive adverts and handing out free fags at dance events and parties. The Indian government says this flouts the country’s tobacco laws; PMI says their marketing strategy is perfectly legal.
India has a huge smoking population whose smoking culture goes back centuries. Obviously, trying to disperse the fog of smoke is impossible, so while there are legitimate reasons for the government to do battle with Big Tobacco over cigarette promotion, you might have thought they would at the same time use every weapon in the armoury to reduce the appalling death rate from oral and lung cancers. Wrong. They want to ban e-cigarettes.
This from the Indian government, “In the absence of requisite provisions under the Cigarettes and Other Tobacco Products Act (COTPA), the health ministry is now examining other laws such as the Drugs and Cosmetics Act and the Food Safety & Standards (Prohibition and Restriction on Sales) Regulation, 2011, to effect a ban”.
"COTPA does not have a provision to ban and, therefore, we are faced with the challenge of finding a strong provision. We are convinced about the harmful effects of e-cigarettes but if we do not back it up with a strong provision under the law, then it will fall flat in the courts”.
Precisely what evidence has ‘convinced’ officials is not mentioned.
In a very interesting move, the Swedish government has chosen not to send in written observations to the European Court of Justice who are hearing the case being brought by Swedish Match against the EU ban on snus.
If you live in the UK, have health insurance and vape, be aware that as far as the insurance companies are concerned, you are a smoker. In a recent survey 43% of vapers had no idea that their insurance could be affected. Seems like the clinicians among us need to convene a meeting of industry representatives and put them straight.
Japan is the market to be in if you want to trial new heat not burn technologies, so much so that its own leading company Japan Tobacco has admitted it is losing ground in the market to rivals such as PMI. With cigarettes sales falling, JT needed to be ahead of the game in Japan’s $10bn market.
A report in the Financial Times said “JT’s loss of initiative in the Japanese HNB showdown is particularly acute in Tokyo, where-white collar salarymen have proved to be eager adopters of Philip Morris’s IQOS smoking system and where, frustratingly for JT, failure to meet early demand for the Ploom left the company settling orders by lottery.” “It’s a pity we fell behind when IQOS and [BAT’s] Glo appeared,” said executive vice-president Hideki Miyazaki at an earnings briefing.
So why have the Japanese taken up HNB options in such a big way? Is Japan different from any country in this respect. To a degree. Gerry Stimson says “One reason for the ready uptake of HNB safer nicotine delivery devices is the Japanese desire to not cause nuisance to or hurt others, plus an interest in gadgets. PMI clearly assessed the nuances of Japanese culture and marketed IQOS in a culturally relevant way e.g. shops looking a little like Apple-stores and appealing to how use of IQOS reduces nuisance to others”. So are the Swedes any different because of their uptake of snus? No, it was probably a question of availability rather than culture. I doubt there is anything particularly ‘Swedish’ about snus. Potentially tobacco harm reduction can be made to work anywhere.
Gerry continues “But Japan us not different in that we can find ways to introduce harm reduction compatible with dominant cultural themes. When I did country and city situation assessments for HIV prevention we encountered 'national immunity myths' ie 'we are not at risk of sexual and drug use transmission of HIV because we are Buddhist, Muslim, Hindu, Catholic, Socialist etc' and our values mean we do not have sex workers, multiple sex partners, gay men, drug injectors etc. I could prove the Minister of Health wrong in 24 hours of fieldwork. The next problem was 'national resistance myths' ie we can't distribute condoms, sterile needles etc because we are Buddhist, Muslim act.. Again untrue. We managed to get harm reduction accepted in many countries including for example Iran where HR was eventually determined by the religious authorities to be allowed under Islamic law. Indeed Iran now has a widespread HR programme including needle exchange and opioid substitution programmes. Indeed, methadone programmes in prison”
“Pursuing the HIV parallels further it's interesting how the IQOS roll out in the UK includes assistance in the use the product (parallels to teaching people how to use condoms or injectors how to inject safely) and encouraging peer to peer adoption of the product (parallels to sex worker and drug injectors peer to peer education)”.
A reasonable response would be, ‘Yes, but if marketing is banned, how do the products get promoted?’ To be honest, I’m not sure that ‘marketing’ in the traditional sense is that crucial any more. There is a fascinating article about Facebook by John Lanchester in the latest issue of the London Review of Books in which he observes that Facebook’s claim to be ‘building communities’ etc is so much equine faeces. At root, Facebook is just a huge advertising agency predicated on the simple idea that the best way to sell product is to get one trusted friend to recommend it to another. So I suspect that with the viral world we live in, the alternative nicotine technology market can grow without major ad campaigns at least of the sort now banned. And just as an aside, this can work even without the interweb. The phenomenal success of Harry Potter was initially driven just by kids recommending it to their mates.