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Opinion: public health, magical thinking and monsters under the bed

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By Barnaby Page ECigIntelligence staff

Counterblasts against Public Health England’s nearly unequivocal support for e-cigarettes were only to be expected, and their trajectory has been laid out by two of Britain’s most eminent general medical journals, The Lancet and The BMJ.

Their main criticisms of the Public Health England (PHE) recommendations are three-fold. First, they say that there is insufficient hard evidence for the much-repeated “95% safer than smoking” maxim; then, they allege that some of its coiners may have been under the malign influence of Big Tobacco; and finally, they dim the lights and whisper that there could well be some vague but awfully scary things about e-cigs which should keep us awake at nights even if they are no more proven than the 95% figure.

Those are not quite the journals’ words, but they’re the gist.

It is true, of course, that PHE chose not to get into the “on the one hand…on the other” equivocation which renders so many policy statements on e-cigarettes practically worthless. Faced with actual public health problems, such as smoking, it decided that the best advice to give on an unproven, unlikely public health problem which might even be a public health boon was simply to relax.

It was not pretending to offer the scientific last word on e-cig safety, but to recommend a sensible approach for now. And quite rightly: the 95% figure may well prove to be inaccurate (insofar as such a generalisation is even meaningful); e-cigs may prove to be 96.5% safer than combustibles, or 78%. But even vaping’s opponents do not seriously propose that the risk levels are remotely comparable.

Unless…ah yes, unless. Unless, through the operation of an irresistible gateway, much spoken of yet never beheld by any mortal, e-cigarette use whisks vapers into the dark realms of tobacco smoking: an occult force so powerful that it overwhelms the will of people whose reason for taking up e-cigarettes was precisely not to smoke tobacco.

This is where the writers of the Lancet and BMJ articles (and dozens of others in usually thoughtful publications) allow smoke to cloud their vision. If there is a tobacco company or a tobacco-related product anywhere on the scene, they seem to believe, then every act or statement or opinion or object in the vicinity can only be one thing: a camouflaged incitement to smoke.


Guilty on all counts


They find linkages to the tobacco industry in the 95% report itself: for example, one corporate sponsor shared an address with a company reported to have accepted funding from British American Tobacco (BAT) for producing an editorially-independent book on harm reduction. But this is barely a smouldering cigar, let alone a smoking gun.

And it is either disingenuous or magical thinking, not to mention insulting both to the scientists concerned and to PHE’s own experts, to believe that a second- or third-hand connection with a tobacco company ineluctably shapes every subsequent statement on the matter.

That is unfortunately a commonly-held view, and one encouraged by the World Health Organization (WHO); its origins are understandable, but when so unbendingly applied it does the debate on tobacco no favours, by stifling voices that can make a genuine contribution.

And this tobacco-phobia, this conviction that the main significance of e-cigarettes is as initiators into smoking, can lead to strange conclusions.

Because there is “concern about uptake of e-cigarettes among people…who would not otherwise smoke”, says The BMJ, it is “equally important to include non-smoking as a comparator”. Yet the concern is merely concern, completely unsupported by virtually all data on e-cig usage; The BMJ’s editors must know this, and surely must grasp the implication that non-smoking is (at most) a far less relevant comparator than smoking, and must know too that evidence for correlation between youth smoking and youth vaping is not evidence for causation.

Yet the scaremongering (and the word is fair) goes on. Speaking of the PHE report, The BMJ says it “offers reassurance that e-cigarettes when ‘used as intended pose no risk of nicotine poisoning to users.’ This is true, but it is equally true of all poisons.”

Yes: and what is the point? How can it be a problem that e-cigarettes are not more dangerous in this respect than other everyday poisons? If “no risk” is unacceptable to The BMJ, what does it actually want: a nonsensical less-than-zero risk? In any case, nobody opposes proportionate safeguards for this, or any other, poisonous substance with consumer uses.


Thinking of the children


Then, it muses, “if e-cigarettes are so safe, presumably there will be no restriction on using them in cars. This will make the forthcoming [British] ban on smoking in cars with children virtually unenforceable because it will be extremely difficult to determine what is causing a cloud of smoke or vapour in a moving car.” And here it descends into the ludicrous.

For a start, it is unlikely that Britain’s police forces will be cruising the roads looking for smoky cars: the ban is likely to be most effective through social pressure, with formal enforcement only coming when breaches are reported or incidentally discovered in the course of other police work.

Moreover, if vaping in cars with children does indeed allow smokers to get away with it on a large scale, there is a simple solution: ban the use of e-cigs in cars with kids, too, just as we ban illegible licence plates, harmless in themselves, because they can aid the commission or thwart the detection of other offences. The suggestion that broad e-cigarette policy should be based on such minute and hypothetical situations is absurd.

The arguing will continue. Public Health England and its supporters have already responded to The BMJ. And both sides do have legitimate points: we should certainly not take our eye off issues of e-cigarette safety, just in case.

But like the hammer-wielding man who sees nails everywhere, the two medical journals seem to perceive e-cigs in a narrow, reductionist complete-avoidance-of-risk context, ignoring people’s real-life preferences, choices and actions. Public Health England’s view is both more nuanced and more practical.

Photo: Matt McGee

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