Is Australia falling behind on tobacco policy?
I’m visiting Australia next week and looking forward to some good discussions with people holding any and all points of view on vaping, nicotine and smoking. My aim is to share experience from the US and UK where we are seeing encouraging uptake of low-risk vaping alongside an unusually rapid decline in smoking. Historically, UK has always had substantially higher levels of smoking than Australia, but in 2016 that gap has finally closed. Both countries have comprehensive tobacco policies – albeit with some differences in the details and Australia generally the first to do new measures, like plain packaging. But there is one major difference. UK (and especially England) now encourages smokers to switch to low-risk alternatives like vaping, while Australia actively prevents it and actually criminalises people who try to protect their own health in this way.
Five talking points inspired by the Royal College of Physicians
The case I want to make is that Australia is missing an opportunity, and there is a human cost for that in terms of cancer, heart and lung disease and premature death. I’ve structured my talking points around five of the key findings of the excellent April 2016 Royal College of Physicians (London) report: see Nicotine without smoke: tobacco harm reduction and press release. It was, of course, the RCP that first put the dangers of smoking on the public agenda with its groundbreaking 1962 report, Smoking and Health.
1. On the relative risks of vaping and smoking
Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure. (RCP Section 5.5 page 87)
People who smoke need to know that they have the option to switch to vaping and that doing this will radically reduce their risks. People involved in health care and policy need to know the same. But much of the public commentary on vaping is so confusing and fear-mongering that very few know they can take this route and benefit from it. The RCP stepped in to provide some clarity and has provided its own best estimate of relative risk based on what is known about these products – and this estimate is independent of other studies. Even though we can’t go fifty years into the future and look back at what happened, it doesn’t mean we know nothing about the risks. Vaping involves completely different chemical and physical processes, and the main harmful or potentially harmful agents in cigarette smoke are either not present or present at levels well below 5% of those found in cigarettes. Even if new harmful agents are found, it is much easier to remove them from e-liquids than from cigarette smoke. Note how carefully worded this is – it is steering the reader to the right ball-park, pointing out it is a cautious estimate, and not making a firm point-estimate prediction. I discuss these numbers in section 2 of my submission to Australia’s House inquiry into vapour technology.
2. On the idea that allowing e-cigarettes will somehow cause people to smoke
There are concerns that e-cigarettes will increase tobacco smoking by renormalising the act of smoking, acting as a gateway to smoking in young people, and being used for temporary, not permanent, abstinence from smoking. To date, there is no evidence that any of these processes is occurring to any significant degree in the UK. Rather, the available evidence to date indicates that e-cigarettes are being used almost exclusively as safer alternatives to smoked tobacco, by confirmed smokers who are trying to reduce harm to themselves or others from smoking, or to quit smoking completely. (RCP Key recommendations)
The finding is what a rational observer would expect – that people use much safer products to reduce the risk to their health and as a way of quitting smoking that works well for them by retaining some of what they like about smoking but getting rid of the almost all of the harm, the stigma and the costs. The rise of vaping in the UK and US has been accompanied by rapid falls in adult smoking, exceeding the rate of decline in Australia – despite Australia’s sharply increased tax and pioneering move on plain packaging. Those who think that the availability and marketing of vaping will somehow increase smoking should be pressed for evidence because it is their theory that is strange and counterintuitive, and the burden of proof should rest with those making this claim. I discuss the respective experience in section 1 of my submission to Australia’s House inquiry into vapour technology. There are no signs of a “gateway effect” anywhere – and the American experience is of rapidly declining teenage smoking coinciding with the rise in vaping, much of which is occasional and without nicotine. This is described in five charts here. Likewise, a 2017 analysis of UK survey data concluded:
In summary, surveys across the UK show a consistent pattern: most e-cigarette experimentation does not turn into regular use, and levels of regular use in young people who have never smoked remain very low.
It is quite possible that teenage vaping is diverting young people from smoking and perhaps ever starting, and could well be beneficial – and this would not be a surprising finding if verified.
3. On the potential for bad policies to cause additional harm
A risk-averse, precautionary approach to e-cigarette regulation can be proposed as a means of minimising the risk of avoidable harm, eg exposure to toxins in e-cigarette vapour, renormalisation, gateway progression to smoking, or other real or potential risks.
However, if this approach also makes e-cigarettes less easily accessible, less palatable or acceptable, more expensive, less consumer friendly or pharmacologically less effective, or inhibits innovation and development of new and improved products, then it causes harm by perpetuating smoking. Getting this balance right is difficult. (RCP Section 12.10 page 187)
For me, this is the best paragraph in the RCP’s report and one that should be held close by policymakers and politicians. This raises a kind of ‘policy double-negative’ that being tough on harm reduction ends up being easy on harm “by perpetuating smoking“. In my submission to Australia’s House inquiry into vapour technology, I summarised the range of possible unintended consequences from bad regulation in Appendix 3. Policy-makers can believe they are being ‘precautionary’ and risk-averse, but actually they are being ‘reckless’ by protecting the cigarette trade and discouraging smokers from quitting. This is perhaps the greatest concern in Australia – that nicotine is allowed onto the market as a consumer product only in a form “prepared and packed for smoking” – what is precautionary about that?. Vaping products, smokeless products and heated tobacco products – all likely to be 90-100% less risky than smoking are simply not not permitted. Why do that? Why grant a monopoly to cigarettes and deliberately prevent people using much less harmful products? There’s nothing precautionary about that.
4. On quitting smoking as a consumer behaviour
E-cigarettes are marketed as consumer products and are proving much more popular than NRT as a substitute and competitor for tobacco cigarettes.
E-cigarettes appear to be effective when used by smokers as an aid to quitting smoking. (RCP Key recommendations, original emphasis)
Vaping products are consumer products marketed as an alternative to smoking. They are not smoking cessation medications any more than diet soda is an anti-obesity drug and the manufacturers do not make therapeutic claims for these products. Most established smoking cessation products are not that effective, doing only a bit better than quitting ‘cold turkey’. But even the best smoking cessation product or technique is of no value if no-one wants to use it. The overall public health impact of any given approach is a function of both uptake and impact on the person’s health. Vaping works on both of these – by being attractive as an alternative to smoking and by mirroring many of the things that people want from smoking it is an effective low-risk substitute. In my submission to Australia’s House inquiry into vapour technology section 1.2, I pointed out we now have 1.5 million ex-smoker vapers in the UK. Coincidentally, the number of UK smokers fell by 1.5 million between 2014 and 2016 (from 9.7 to 8.2 million). Another 1.1 million people both smoke and vape – and many may be on a journey to quitting or substantially cutting down.
5. On the approach that public health policy-makers and agencies should take towards vaping
However, in the interests of public health it is important to promote the use of e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK. (RCP Key recommendations, original emphasis).
Professor John Britton, chair of the RCP’s Tobacco Advisory Group, said:
The growing use of electronic cigarettes as a substitute for tobacco smoking has been a topic of great controversy, with much speculation over their potential risks and benefits. This report lays to rest almost all of the concerns over these products, and concludes that, with sensible regulation, electronic cigarettes have the potential to make a major contribution towards preventing the premature death, disease and social inequalities in health that smoking currently causes in the UK. (Press release)
There it is: a strong recommendation from the Royal College of Physicians to embrace the concept of tobacco harm reduction as a public health policy. That is not an alternative to other tobacco policies – in fact it makes the traditional tobacco control policies more effective and less ethically challenging. For example, if the government raises cigarette taxes (as it is doing aggressively in Australia), it places a regressive burden on poor or otherwise disadvantaged smokers. If they have a low-cost, low-risk alternative to switch to, cigarette taxes may have the desired health effect by promoting switching and it could reduce the growth of the black market and related criminality and home grown ‘chop-chop’, now starting to take hold.
This message has been taken on in England and to some extent, the UK. I have gathered all the examples of where England/UK is taking a leadership role in this new phase of tobacco policy: Vaping and tobacco harm reduction – highlights from England.
Could Australia regain tobacco policy leadership?
When the facts change… Australia has always had a reputation for leadership in tobacco policy. But that may not be true now. Since 2010, a significant technology disruption has emerged and creates huge opportunities that could ultimately see the end of smoking – and with the consent of smokers rather than by taxing, coercing and stigmatising them into quitting. What an opportunity! The trouble is that the Australian public health establishment has so far decided to fight progress instead of embracing it. That could change quickly, as it did in the UK from 2014. It just needs a few leaders in the field to see the way ahead and to challenge the prevailing orthodoxy. This technology disruption did not exist until recently – the facts are changing:
“When the facts change, I change my mind. What do you do, sir?”
Attributed, probably incorrectly, to the economist John Maynard Keynes.
UK does not have the optimum policy. If Australia moves from prohibition to regulation of vaping, it has one really big advantage over the UK. Australia can define the regulatory environment from scratch, and to do it right. The UK does not have the flexibility to do this, because it is bound by the EU Tobacco Products Directive – and this was made in a different time when less was known and the European Commission and governments, including the UK, wanted to regulate these products over-cautiously. That directive is an awful piece of legislation… see: what is wrong with the Tobacco Products Directive for vapour products, but we are stuck with it and probably even with ‘Brexit’.
But could Australia become the world leader…? There are really only four main strategies in tobacco control: promote cessation; prevent initiation; protect bystanders; and reduce harm to users. New technologies have made the harm-reduction strategy much more important and viable, but this is where Australia is now falling behind. In my submission to Australia’s House inquiry into vapour technology section 4, I gave my views on what a leading policy on vapour technology could look like. Taking advantage of more recent knowledge, Australia has a ‘second-mover’ advantage and could define the world’s best policy on tobacco harm reduction. Now that really would be leadership.
But don’t dither – the others are on the move: there’s a new approach at United States FDA, a major rethink in Canada and New Zealand is moving forward.