Marie McInerney writes:
Are electronic cigarettes – or e-cigarettes as they’re known – the silver bullet that will finally cut down smoking rates in the most “hard to reach” groups, including Indigenous smokers?
Or are they the latest ruse of a shameless industry that risks kick-starting smoking rates again, splitting the tobacco control movement and drowning out other important debates on tobacco control measures in the media?
New Zealand public health expert Professor Richard Edwards is one who believes there’s a real risk to the unity of the tobacco control movement from the “heated, sometimes vicious” debate on e-cigarettes which has seen different jurisdictions, from Australia to Scotland and beyond, take very different approaches on their sale and use.
It’s a complex and evolving debate but, in a nutshell, e-cigarettes advocates say they are a far less harmful alternative to tobacco and will help smokers quit or act as an effective substitute means to access nicotine.
Those against making e-cigarettes more easily available say they risk normalising smoking again, may be a “gateway” to tobacco particularly for young people, and may pose significant health risks to users.
Edwards says these are important and legitimate issues to debate, but he fears that entrenched positions and ad hominem arguments may play into the hands of the tobacco industry and put other tobacco control gains at risk.
Divide and conquer
At the recent Oceania Tobacco Control Conference (OTCC) in Hobart, Edwards reminded delegates of Phillip Morris documents about Project Sunrise from the 1990s, which laid out a divide-and-conquer strategy against the tobacco control movement.
One executive memo hailed “a sense of invincibility” within the movement that “might blind organizations to carefully orchestrated efforts by the tobacco industry and its allies to accelerate turf wars and exacerbate philosophical schisms…”.
Edwards is a cautious supporter of e-cigarettes as one tool in the fight to reduce smoking rates, but said:
Regardless of whether or the extent to which e-cigarettes have a positive impact on reducing smoking, if they also have an impact to derail, distract and disunite the tobacco control movement… that could result in them being quite harmful, and fracturing the tobacco control movement.
I think that is something we should strive to avoid.”
A leading Australian tobacco control expert, the University of Sydney’s Dr Becky Freeman, agreed at the conference that the debate over the veracity and strength of evidence to determine how best to regulate e-cigarettes has divided the tobacco control sector locally and globally.
She is not so worried about a deep split within the sector in Australia, where she says “the vast majority in tobacco control are still cautious”, despite the passionate advocacy of proponents like University of New South Wales Professor Colin Mendelsohn who made headlines in August with a contested claim that smoking reduction rates had stalled.
Australian Drug Law Reform Foundation president, a harm reduction advocate, Dr Alex Wodak, is also a leading proponent of e-cigarettes, regularly speaking out on the need for reform (including on Twitter):
Fact that cigs cost low income Oz smokers $10K/yr (& rising!) vs #ecigs $1K/yr is another reason to ban ecigs-to punish the poor!
How can #ecigs be gateway when US smoke rates falling so quickly?
Freeman’s bigger worry about the debate over e-cigarettes is how it tends to “detract and derail” media coverage and research and policy focus, at the expense of other critical tobacco control policy reforms”. She would rather be discussing the impact of greater restrictions on tobacco retail supply.
Letting the genie out
Every two years the Oceania Tobacco Control Conference brings together people working in tobacco control research and policy and smoking cessation services in Australia, New Zealand and across the Pacific.
At the 2015 event, high profile public health campaigner Professor Simon Chapman – the bête noire of e-cigarette advocates – warned Australia not to ‘let the genie out of the bottle‘ like the US and UK had in their decisions to legalise e-cigarettes.
Two years on, Australia still has the stopper firmly in place.
On the day before OTCC17, Federal Health Minister Greg Hunt vowed that he would not lift the ban on e-cigarettes, despite an ongoing parliamentary inquiry into their use.
“It’s not going to be happening on my watch as far as I’m concerned,” Hunt said in an interview on Triple J, surprising even the tobacco control delegates with his vehemence.
“I have a very strong, clear, categorical view that this is not something that should occur in Australia,” he said.
But New Zealand, struggling to meet its Smokefree 2025 goal of bringing down overall smoking rates to less than five per cent, has popped the cork.
It announced earlier this year that it would legalise the sale of nicotine e-cigarettes in 2018 and last month its Health Ministry endorsed the use of e-cigarettes – or “vaping” as it’s known – as a harm reduction aid and smoking cessation tool.
While not proffering conclusive evidence, it said it believes e-cigarettes “have the potential to make a contribution” to Smokefree 2025 and “could disrupt the significant inequities that are present”, particularly among Maori and Pacific smokers.
It’s a move that Richard Edwards supports, as long as it doesn’t mean all tobacco control efforts now focus in one direction:
E-cigarettes seem likely to overall have a net positive effect on reducing smoking prevalence, though because they are unlikely to be the whole solution, we should continue to use existing and new tobacco control approaches to make smoked tobacco products less affordable, less available and less appealing.
These interventions will also enhance the positive impacts of e-cigarettes.”
The differing views between Australia and New Zealand echo differing approaches elsewhere.
The Guardian recently reported on the “major public health divide” between researchers in the United States and United Kingdom on e-cigarettes, “who have respectively focused on the potential harms or benefits of vaping.”
And the debate and advocacy has not died off in Australia in the wake of Hunt’s comments, particularly following recent visits to Australia from leading UK advocates: London’s Queen Mary University Professor Hayden McRobbie and Clive Bates, the former head of Action on Smoking and Health (ASH) UK and a leading advocate for e-cigarettes in the UK.
Alongside another former head of ASH UK, Bates gave evidence last month to Australia’s Standing Committee on Health, Aged Care and Sport inquiry into the use and marketing of electronic cigarettes and personal vaporisers in Australia.
The committee chair observed it had been “all-England week” for the inquiry, with their appearances coming on top of evidence from the House of Commons All-Party Parliamentary group for E-Cigarettes and Public Health England, which in 2015 declared that e-cigarettes are significantly less harmful to health than tobacco and have the potential to help smokers quit smoking. (See criticism of their stand here.)
The momentum led recently to a report on Radio National’s The Health Report asking: “E-cigarettes: Is Australia missing out?”
Debate has shifted in NZ
New Zealand’s decision to legalise e-cigarettes has been heartily welcomed by Zoe Hawke, General Manager for the National Maori Tobacco Control Leadership service at the Auckland based Maori public health organisation, Hapai Te Hauora and a member of the Indigenous committee that advised the recent OTCC conference.
Hawke’s support for e-cigarettes is driven by the tobacco toll for Maori people, particularly for women – 42 per cent of Maori women smoke, versus 34 per cent of Maori men and 15 per cent overall in New Zealand.
“We’re not saying that e-cigarettes are the silver bullets but what we’re seeing on the ground more and more is that Maori women are quite interested in them, they want to know more about them, they see promising new innovative products that possibly could help them transition off tobacco and we are listening to what they’re saying”, she said.
She concedes e-cigarettes are challenging for many of her colleagues in tobacco control and admits to having had some concerns herself on various levels, but she doesn’t think the sector can afford to ignore the potential for Maori people.
“At the moment, if you go to a traditional cultural cemetery, it’s full of our loved ones who have died of tobacco related illness,” she said.
Hawke admits there’s no evidence yet showing that e-cigarettes will stop Maori people from smoking, but says she is looking forward to the results of studies currently in progress.
Hapai has supported researchers to link with Vape2Save, a community-based program in Auckland (which provided a submission to Australia’s inquiry), to interview group participants around their experience with vaping.
“(Maori women) attend these stop smoking group sessions, held in community, in numbers I’ve never seen before,” she says. “It’s pretty amazing.”
Hawke believes the debate has shifted in New Zealand, where even those in tobacco control and smoking cessation who are unconvinced by the evidence so far around e-cigarettes are “still receptive” to their potential. Now she says debate is more around where they should be sold.
Australian observers suggest the different approach is being led by those who work in smoking cessation programs, where the impact can be seen individually, versus the bigger population health approach that Australia takes. But Hawke says tackling Maori smoking rates requires both population level and individual based approaches.
Her sense is that there may be less concern in New Zealand about the hand of the tobacco industry in e-cigarettes, perhaps, she says, because it currently has strong independent tobacco industry-free vaping speciality shops.
“I’m guessing Australia is still very suspicious about the tobacco industry and what it has planned,” she said.
“I can totally understand that but what could Australia then potentially be missing out on for its Indigenous population and the choice in regards to cessation tools? I’m not sure, but I know it is doing something for Maori here in New Zealand.”
Opening her keynote address at this year’s OTCC, Becky Freeman told delegates she had been delighted to be asked to present by Sarah White, Director of Quit Victoria and Chair of the OTCC Program Committee – until she found out what her topic was to be.
“When she said it was on e-cigarettes, I said ‘I’m going to hang up the phone, run away and change my number’,” Freeman laughed, pointing out that her dress was the colour of “rhino hide” and she was “fully prepared for what comes my way”.
It was an acknowledgement of the intensity of lobbying for legalising of e-cigarettes, particularly on social media, where vaping advocates rarely let an opportunity go by to make their case, generally portraying those who won’t support e-cigarettes as elitists living in ivory towers, nanny state nuts, or ‘closed shop’ villains hanging onto their patch.
Introducing Freeman’s session, White said there was nothing in tobacco control to match the “interest, publication rate, passion, and vitriolic language” around e-cigarettes. She said:
One thing that’s for sure is there are a lot of passionate advocates on both sides.
And unfortunately a lot of that debate is being transduced through soundbites by subeditors, and the scream register has been turned up full bore, particularly by groups of small but vocal and sometimes pretty nasty keyboard warriors.”
Via Twitter and elsewhere on social media, vaper advocates invariably declare they have no ties to the tobacco industry, and describe themselves merely as passionate users, consumer advocates, champions of choice, and wanting to save lives.
One told Croakey he was motivated by “25 years a smoker, 10 years research and self-experimentation: Not in the pocket of Tobacco Industry or Tobacco Control Industry”.
“They’re blocking the fire escape,” he said of the broader Australian tobacco control sector. “Three million Australians who smoke are being denied a vastly safer alternative.”
He then asked whether Croakey funding from the Public Health Association of Australia “influences what you feel you can write about the issue?” (Ed’s note: Croakey’s $30,000 pa funding arrangements are declared here, including an MoU of editorial independence under which members of the Croakey funding consortium, auspiced by the PHAA, have no say over editorial coverage or content).
For some, the vaper advocacy may be true grassroots activism. But the single interest focus, uniformity of message, speed of engagement and venom from many raises questions about orchestration and commercial interest among some advocates for the e-cigarette industry, currently valued globally at around $3 billion.
In his Triple J interview, Minister Hunt was clear about who was behind the push for policy change: “It’s big tobacco which is arguing the case for these e-cigarettes and they’re only doing it because it’s in their interests,” he said.
Australian tobacco control experts at the conference said we only need to look at the creation of Philip Morris’ so-called Smoke Free Foundation, condemned by the World Health Organisation, to appreciate on how many levels the industry fights.
And they say that while Scotland, the UK and New Zealand may see the benefits more than the risks, Australia is not out on a limb: sales of e-cigarettes are banned in 26 countries, 18 regulate them as medicinal products, 26 as tobacco products and four as poisons.
Reviewing the evidence
A joint position statement from Cancer Council Australia and the Heart Foundation makes detailed recommendations for regulation, and says “the limited evidence available points to a risk that widespread electronic cigarette use could undo the decades of public policy work in Australia that has reduced the appeal of cigarette use in children” and that the short and long term health effects of electronic cigarette use “remain unknown”.
NSW Health factsheets raises many questions about the safety of e-cigarettes and say there is limited research available on whether electronic cigarettes can help people to quit smoking, and that the body of research to date shows “mixed results and unclear conclusions”.
This BMJ paper reviewing international regulation (between September 2014 and October 2016), identified 68 countries regulating e-cigarettes through a variety of mechanisms, including through banning their sale, and expanding tobacco control laws to e-cigarettes including vape-free public places and age of purchase laws that mirror laws for cigarettes. About about a third do not have regulations specifically written for e-cigarettes, rather they apply existing tobacco control regulations to these products. The authors note that “this may or may not be consistent with the intent of the original laws”.
A 2016 report by the World Health Organization, Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS), reviews the evidence around the use of e-cigarettes, and says the involvement of traditional tobacco transnational companies in the marketing of ENDS/ENNDS “is a major threat to tobacco control”. It says there are concerns that tobacco companies are marketing ENDS/ENNDS in order to minimise the threat to tobacco sales by promoting ENDS as a complement rather than an alternative to tobacco, or controlling technological innovations that would prevent improvements in their efficacy as an aid to cessation.
Meanwhile, in England, the Parliament’s Science and Technology Committee has just launched an inquiry into the health impacts of e-cigarettes, the suitability of regulations guiding their use, and the financial implications of a growing market on both business and the NHS. The Committee said an estimated 2.9 million adults in the UK are using e-cigarettes – up from 700,000 in 2012.
The precautionary principle
Presenting her keynote, Freeman said much has happened on the e-cigarettes front over the past couple of years, with products becoming increasingly sophisticated and many studies interrogating their use and regulation.
She prefaced her presentation by saying she didn’t have anywhere near the time needed to go into a range of contested or under-researched areas – and there are many – such as youth initiation and possible “gateway” or protective effects, harm reduction, tobacco industry engagement and influence, advertising and promotion, health effects, re-normalisation of smoking and so on.
Instead, she provided an evidence review on the key question of whether e-cigarettes can help smokers to quit, drawn from the following:
And her verdict?
“We’ve had some advances in research but not enough to say we have a bedrock of evidence that e-cigarettes help you quit,” she said.
“In fact the evidence we have now suggests we should be extremely cautious about saying e-cigarettes at a population public health level help smokers to quit,” she told delegates.
Freeman says she hates to sit on the fence on such a critical issue but she believes that’s a “researcher’s prerogative” and thus the precautionary principle should still apply.
In the end, she says, there’s still too much risk.
“I’m really fearful that because cigarettes are so harmful – really nothing compares to them – that we have a really low bar of product safety that we will just allow some fly-by-night industry to conduct mass population experiments because their products are ‘safer’.”
We’ll conclude as she did:
• Bookmark this link to follow our coverage of #OTCC2017. And flashback to Marie McInerney’s reports from #OTCC15. Download the full conference report here from the Oceania Tobacco Free Conference, held in Perth with the theme, “let’s make smoking history”.