Tobacco Harm Reduction: recommended reading

A chance to catch up with the wide-ranging coverage of Weekly Suggested Reading in Tobacco Harm Reduction. It is presented in a blog and is well worth a look at previous posts.

Tobacco harm reduction is a term that carries many meanings depending on who uses it.

ASH Scotland: Assaulting smokers with bilge about third-hand smoke

The anti-smoking professionals are getting a bad press this week, but this gets even worse.

A briefing called Third-hand Smoke has appeared today. It was only a matter of time as ASH Scotland has been gathering information on Third-hand Smoke for some months now. The opening is classic ASH Scotland:

• the ‘three r’ definition of third-hand smoke is that it describes residual tobacco smoke pollutants which remain on surfaces and in dust after tobacco has been smoked, are re-emitted back into the gas phase, or react with oxidants and other compounds in the environment to yield secondary pollutants
• even without understanding what third-hand smoke is, people have long been aware of its presence and are beginning to understand how it can affect clothes, hair, cars and homes, and create stains and odours
• existing evidence on THS suggests a strong need for further research to close gaps in the current understanding of the chemistry, exposure, toxicology, and health effects, as well as behavioural, economic, and socio-cultural consequences
• whereas there is a long-established evidence base for the health impact of second-hand smoke, there is still a lack of human health studies on the potential health impact of third-hand smoke
• the greater and more quantifiable health dangers from SHS suggest that health professionals should focus on reducing exposure to SHS, including by promoting smoke-free homes and vehicles. [italic emphasis added]

In other words, 'people know that smoke is smelly and stains things over time, but we haven't be able to demonstrate any health effects in the literature yet. We can still carry on pestering you about secondary smoke though.' Well, that was worth a shed-load of taxpayers' money. Curiously, it then goes on to explain that residual smoke reacts with oxides and other chemicals including nitrous acid, which is 'produced in engine exhaust emissions but is also a common indoor pollutant produced by poorly vented domestic gas appliances'. Wouldn't it be better to maintain regular checks on these gas appliances than to mess about warning people on third-hand smoke, which they don't even know is dangerous? Researchers have so far failed to find harmful doses of any substances in third-hand smoke even when increasing nitrous acid concentrations to levels much higher than normal. But that won't stop belief in the concept. One respondent even cites third-hand smoke as a reason to ban electronic cigarettes.  

The third-hand smoke briefing from ASH Scotland shows limited understanding of second-hand smoke too. In one sentence to describe second-hand smoke it says: 'Research demonstrates that tobacco smoke is a toxic substance with no safe level of exposure, and that the risks from exposure are largely dose-related' [emphasis added]. If it's dose related, why won't a tiny little dose cause negligible damage? (oh, dear!) 

This third-hand smoke concept is insidious. It fits so well with the denormalisation of smokers. Having removed smoking from the public sphere, it now follows them to the private sphere. Question – What could be the intention of this kind of statement?: 

A 2010 study* indicated that third-hand smoke accumulates in smokers' homes and persists even after homes have been vacant for two months and are cleaned and prepared for new residents; the study suggested that non-smokers living in former smoker homes are exposed to THS in dust and on surfaces. (* Matt, George E et al. When smokers move out and non-smokers move in: residential thirdhand smoke pollution and exposure. Tobacco Control, 2011;20:e1. http://tobaccocontrol.bmj.com [Accessed 06 May 2011])

Answer – to devalue the effects of smokers: the properties they own, or rent. To impoverish them, basically. And to devalue smokers as buyers of property and (especially) as tenants. Note that this study emerged in 2010, and they still, half-way through 2011, don't have any evidence that third-hand smoke harms anyone. Yet they are printing this rather inflammatory material  It talks of a potential health hazard to infants: no sick babies to hand, just potential research contracts.

A further purpose is to continue pushing ASH Scotland's agenda to get people smoking outside. ASH Scotland's strategy document Beyond Smoke-free includes the following in its short-term aims:

We must develop robust intermediate and endpoint targets to reduce second-hand smoke exposure in the home and in vehicles, in order to support awareness raising work and work in communities.

And the following in its medium-term aims:

We need to be realistic about the difficulties some people have. We must promote effective harm reduction strategies, including the use of nicotine replacement for temporary abstinence, to protect children from exposure to secondhand smoke in the home. 

All the more easy for them, if they can persuade enough people of the dangers of third-hand smoke without needing to prove it or even show any understanding of it. The briefing does say that the research on third-hand smoke is not conclusive. But it is 'aimed at parents and carers', talks about infants crawling across the carpet and generally attempts to stir the shit on the basis of lucrative speculation, in pursuance of its agenda.

Policy by public opinion poll according to ASH Scotland

The lull in anti-smoking legislation will soon be over, and Sheila Duffy will soon stop reminding the incoming government of its obligations to children and get down to some serious work. Her latest effort claims:

Our polling shows that the public are aware that there are risks to children’s health from exposure to tobacco smoke with a huge 88% saying that they think second hand smoke increases the risk to a child’s health ...

The agenda has clearly moved to children (adults are no longer exposed in the workplace), meaning we can expect restrictions on smoking in homes and cars. The reasoning is superbly executed ... most people think smoke endangers children, therefore policy must be 'x'. (Are most people right? We should be told, but not only by Sheila Duffy.) More:

This is not necessarily about getting smokers who look after children to quit. Rather it is about informing people about the harms caused by tobacco smoke and showing parents and carers that the best way of protecting their children from the harm caused by second hand smoke is to not smoke around them.

So they are not even bothered about getting adults to quit any more. They are after 'harm reduction', which means nicotine replacement therapy in ASH Scotland's language. This means that they may have absorbed the wisdom imparted by the likes of Tim Coleman that NRT doesn't work for most people once they have left the clinic. That is, it doesn't work as a quit smoking tool, but it can still be used to relieve temporary discomfort.

Ms Duffy then goes on to recommend a 'social marketing campaign' covering the dangers of passive smoke exposure to children. What happened to public information campaigns? The term 'social marketing' is itself instructive, as marketing is a form of deliberate persuasion. The messenger is quite uncritical of the message: it has been taken for granted as fact, removed from the realm of objectivity, and given to the marketers to deliver to the public.

ASH Scotland has yet to start pushing for third-hand smoke awareness, but it's only a matter of time. Third-hand smoke is discussed clearly by Chris Snowdon here; he quotes author Winickoff from a private email regarding his study on third-hand smoke:

Basically, the study found that IF you believe that thirdhand smoke is harmful to infants and children, then you were much more likely to have a home smoking ban.

Not much science there either really, is there? More logic, really, and certainly doesn't address the issue whether third-hand smoke is a danger to children, or an issue that would make it advisable to wear a face mask when changing bed linen. The line of argument is identical to Sheila Duffy's. If enough people believe it's dangerous, there is no need to prove it any more.

Tobacco harm reduction: NICE makes a silk purse of a sow's ear

The National Institute for Clinical Excellence has reinvented tobacco harm reduction.

It's a poorly guarded secret that smoking cessation treatments don't work. The tobacco control professionals know this very well. Their strategy is therefore changing.

NICE has a section dedicated to harm reduction in tobacco. It even has its own email address, and a list of registered stakeholders. In seeking to promote harm reduction, they have published a draft  consultation paper, aimed at professionals in smoking cessation and public health managers, with a view to publishing guidance about harm reduction.

The consultation begins with a preamble making emphasising: 1) the health toll from smoking; 2) health inequalities reflected in smoking rates; 3) the dangers and recorded damage caused by passive smoking in the home; 4) people's wish to quit and low rates of success. (They still insist that NHS help is more effective than cold turkey.) It also explains the methods that it includes and those it specifically excludes (including hypnotherapy and all other alternative therapies).

Excluding therapies with a known track record from an approach that calls itself harm reduction seems odd, but not unexpected in the field of smoking cessation.  In fact the consultation paper includes e-cigarettes in its methods. But the overall point seems to be that although smoking cessation meds don't work they still have their place for people who want to cut down smoking, whether for their own health or other people's. Is this the answer to Tim Coleman's prayer – a passport to keep people on smoking cessation meds for longer periods, especially people on low incomes?

Were it not for the fact that they are playing another guilt trip on smokers for damaging their loved ones and putting themselves at risk, this could almost be taken for benevolence. It appears that the pharmaceutical apron strings are still pulling tight.

The authors of the questionnaire seem a little confused about the ethics of promoting smoking harm reduction rather than complete withdrawal:

Question 8: Are there any unintended consequences from adopting a harm-reduction approach, for example, does it deter people from trying to stop smoking?

Question 9: How can practitioners deliver the complex messages about harm reduction without weakening advice about the benefits of stopping smoking?

But they do ask:

Question 10: Does long-term use of pharmacotherapies or ‘nicotine-containing products’ to reduce smoking have any ill-effects on health?

... surely another opportunity to complain about Champix at the highest level!

Organisations can become stakeholders by registering (details here). The list of stakeholders is dominated by 'public health interests', but both the Vapers' Network and Tobaccoharmreduction.org have also joined up. Organisations that represent patients are eligible to register: that means any smokers or users of any kinds of tobacco, since they seem so keen to treat smokers as patients. (It doesn't appear to cover Scotland, however.)

Regular reviews on Tobacco Harm Reduction

Tobacco harm reduction is a controversial area. I can't comment on the science but I can give an outline. The premise of tobacco harm reduction is that smoke, rather than nicotine, is what makes smoking dangerous. Consequently smokers who want to give up can use smokeless tobacco or e-cigarettes more safely than smoking tobacco.

The emerging tobacco harm reduction market has benefited from scares about the dangers of smoking to by-standers. Urging people to give up smoking has always been easier if you can persuade them that smoke is killing their loved ones. In fact ASH Scotland uses the term 'harm reduction' here (a section from Sheila Duffy's epic 'Beyond Smoke Free' document), to mean that using nicotine replacement therapy beats smoking in front of your children. She seems to feel that smokers should be content with a 'sticking plaster', rather than a satisfying experience.

Users of e-cigarettes and other smokeless tobacco have found themselves faced with the threat of prohibition far more quickly than smokers. The market for e-cigarettes has clearly competed for the same customers that might otherwise have bought nicotine patches and gum from global pharmaceutical companies. Pharmaceutical companies want to develop drugs based on natural substances like tobacco, and the entire anti-smoking establishment has sought to make e-cigarettes unavailable to consumers, in the hope that it will create a captive market for pharmaceutical cessation products (see forum discussion here).

Users of e-cigarettes know that banning their product is not to do with health (even though spurious claims are made about uncertain health risks). They can see cigarettes still on the market, while the product they resorted to in order to stop smoking has been banned – leaving them with the options of stopping smoking without any help or buying the products of pharmaceutical interests.

Smokers have lived with their chosen product being taxed to the heavens: e-cig users live with the threat of their product of choice being made unavailable (for much the same reasons as the rest of us will no longer be able to buy calendula lotion or other common herbal products after 1 May). For most people an e-cigarette ban remains a threat rather than actuality (New York State being closest to an outright ban in the US, and full bans operating in Brazil, Singapore and in Canada except where the e-cigarette is free of nicotine – see here for details).

This guide to essential reading on tobacco harm reduction offers further links and insights. Stories include a possible workplace ban on e-cigarettes in Georgia (together with suggestions for local action) and the opposition of students at the University of Massachusetts to a smoking ban that included e-cigarettes and smokeless tobacco in its reach. There's much more where this came from, and the list will be regularly updated.

Non-communicable diseases and harm reduction threaten the world?

Well, do they?

Guardian health blogger Sarah Bosely thinks the name non-communicable diseases isn't quite sexy enough to get people concerned and motivated as they were about HIV and AIDS. Quoting a Professor Beaglehole in The Lancet:

The spread of non-communicable diseases (NCDs) presents a global crisis; in almost all countries and in all income groups, men, women and children are at risk of these diseases. Worldwide, substantial gains have been achieved in economic growth, health, and living standards in the past century. This progress is now threatened by crises of our own creation–climate change, finance and food insecurities, and the crisis in NCDs, principally heart disease, stroke, diabetes, cancers, and chronic respiratory disease.

Do I think this is alarmist? Yes, to the extent that non-communicable diseases can't be considered by anyone's standards as threatening to human life as diseases that spread through populations by contagion or infection.

We are told that 'two-thirds of all deaths globally are from NCDs every year - and four out of five of those deaths are in low and middle-income countries. One third are in people aged less than 60.' I have a table in front of me with UK mortality from 2003, a year when the total mortality was 610,871, of which 397,609 were over 75. Before I saw the table I never imagined that living to 75 was normal! In early 2000s UK, two-thirds were living more than 75 years, compared with two-thirds globally surviving 60, as in the Lancet report. I am not sure why it should come as a shock that one-third should die before the age of 60, and I don't see why it should be surprising that heart failure or failures in the respiratory system should cause fatal collapses in people of all ages, since these are the vital systems that keep our bodies going.

I'n not quite sure what's driving the non-communicable diseases campaign. They want to advance tobacco control (are people in low and middle income countries aware what vicious proportions anti-smoking campaigns can assume?), and tackle salt consumption as well as going for more specific campaigns, such as improving HPV protection in young women.

The cynic in me says they want to distribute more drugs and push for more restrictive tobacco and alcohol laws. It says that the figures tell us nothing about quality of life but treat longevity as a goal for good or ill, and that anti-smoking campaigns of the kind seen in this country are not likely to increase the sum of human happiness. How do they propose to cut down people's consumption of salt?

We know how to tackle the tobacco companies and fast-food chains. We have the pills to protect people from cardiovascular disease. Our teenage daughters are being protected from cervical cancer - and the same jab ought to be available in countries where the death toll is far higher than it is here.

Nothing to be cynical about at all really, is there?

Note the confidence in being able to 'tackle the tobacco companies'. Has it occurred to these worthies from the global health community that a less doctrinaire approach to their pet projects might save more lives? A European Commission public consultation on revising the 2001 tobacco directive included the suggestion of banning snus throughout Europe. Snus, chewable tobacco, is considered to be far less injurious to health than smoked tobacco, but the logic of anti-smokers dictates banning because it carries unknown risks.

Hat tip to Dick Puddlecote for this part of the story: a link to former director of Action on Smoking and Health Clive Bates, discussing a position paper on snus from 2007 in a blog post entitled Saying stupid things with fake sophistication:

So the main ASH Scotland policy idea is that other countries should be prevented by law from reaching a position where more of the tobacco use is through far less harmful forms of tobacco consumption and that addicted individuals should be prevented by law from having access to lower risk products. What next? A ban on anti-lock brakes? Cycle helmets? Ropes while rock climbing? Any risk reduction measures at all while engaging in inherently risky behaviour? There's the warped logic of the overweening health planner behind all this ... if you make a risky activity much safer, then people might not stop doing it altogether.

Can you imagine Clive Bates getting a job with ASH or ASH Scotland today? He opines, 'No less than 266 references are used to support the truly stupid idea that smokeless tobacco, which can substitute for cigarettes and is far less hazardous, should be banned. He says, 'Even tobacco companies provide better and more balanced analysis than this effort by ASH Scotland' [emphasis added]: stop right there!

Clive Bates defends the idea of harm reduction: people can choose vastly less harmful products than smoked tobacco, and it is perverse to obstruct the public from choosing safer alternatives.

Tobacco control, the whole community, will favour outlawing snus. This makes them the worst possible candidates for advocating global tobacco control because they will 'encourage' countries to ban these products, which are safer than tobacco, in their attempts to reduce cancer rates, heart attacks and respiratory problems. Does this increase our confidence that they can effectively tackle non-communicable diseases? Not really.

ASH declared interest in GlaxoSmithKline, 2001

In 2001, then head of Action on Smoking and Health Clive Bates wrote to the Chief Executive Officer of GlaxoSmithKline, protesting at the appointment of a tobacco industry representative Derek Bonham on its board of directors. Bates felt that a conflict of interest was involved: the public already in 2001 had identified collusion between pharmaceutical and tobacco interests:

There are already campaign groups that claim the tobacco industry and pharmaceutical industry have a symbiotic relationship that is parasitic on the smoker. I believe it would be highly damaging to the category, to the company and the industry as a whole would be highly damaging to feed that cynical perception.

News to me if the public had any such 'cynical' perception ten years ago.

The letter says:

1. that Action on Smoking and Health had a 'small holding' in GSK
2. that Action on Smoking and Health was instrumental in getting smoking cessation treatments accepted by the Department of Health in London

It identifies policy measures, such as raising prices and increasing regulation of tobacco, that benefit 'the smoking cessation market' at the expense of the tobacco market.  'Every time a smoker switches to "lights" as
an alternative to quitting the market for smoking cessation is diminished.' Clive's letter lists measures that he believes promote the smoking cessation market at the expense of tobacco:

• Restrictions on smoking in public places and workplaces
• Marketing restrictions on tobacco companies
• Higher tobacco taxation
• Greater NHS involvement in smoking cessation
• Regulatory measures to be applied to tobacco products.

Tobacco companies and pharmaceutical companies carrying nicotine replacement treatments are competing for the same market: that of smokers. To that extent, there is a logical conflict of interest.

Nicotine replacement therapies became available on the NHS in April 2001. The Guardian was excited about this move soberly  reporting John Britton's then-cautious estimate that NRT doubled a smoker's chance of quitting (the claim escalated to a quadrupling of the cold-turkey quit rate). In those days one could say:
'this doubled success rate only applies if you are ready to stop. Taking NRT cannot make you more committed to giving up smoking or transform you into a non-smoker, although it can help end the psychological habit of reaching for a cigarette.'

Even giving nicotine treatments to kids as young as 12 didn't raise any scepticism among Guardian writers on health.

The early days saw campaigners fighting for greater availability of NRT, using the same harm reduction arguments now used by campaigners for e-cigarettes. Said Anne McNeill (now at the UK Centre for Tobacco Control Studies): 'It's simple really - the more the regulators place stringent regulations on the use of NRT, the more likely it is that people will continue to smoke, and then die as a result.'

My question is – the smoking cessation market is important to Clive Bates. No doubt he believed it would help smokers to give up smoking. But what is it worth (as an investment) to the NHS, when it's clear that much of it will go out free on prescription?

Just asking.

Tobacco harm reduction partially explained

Harm reduction means different things to different people. In the context of nicotine, it means using smokeless alternatives to tobacco without resorting to nicotine-based cessation therapies. It's a fairly new area to me, but it's been interesting how e-cigarettes are almost as political an issue as smoking itself.

E-cigarettes are, of course, an obvious example of harm reduction. Whether or not you believe that smoked tobacco is as serious a problem as the authorities wish us to believe, it is unarguable that using an e-cigarette doesn't involve inhaling in the way that smoking involves inhaling, and that it creates water vapour and not smoke.

Many e-cigarette users are far more politicised than smokers, and it is small wonder. Having given up the trouble to give up smoking, perhaps having swallowed anti-smoking propaganda in the process, they that find the product (e-cigarette) that has enabled them to stop smoking is about to be banned in New York, on suspicion that it might present some kind of health risk to the user.

At least that's the official version. In fact they are banning e-cigarettes but not real cigarettes (from which they derive huge levels of tax, but which (officially) carries enormous health risks), or drugs such as Champix, which is the subject of hundreds of lawsuits. New York State wants smokers on either real tobacco or pharmaceutical drugs.

Even ASH Scotland dedicates a section to harm reduction. Its sole item for 2011 so far shows that a few dozen smokers in the US prefer nicotine lozenges to snus. Its briefing on e-cigarettes is full of waffle, but essentially it wants e-cigarettes regulated by the MRHA along with any other smoking cessation treatment.

Unofficially, smokers find an alternative to smoking that's acceptable to them and take to it in their thousands. Officially, the authorities realise that they no longer control the nicotine market (the punters do – shocking!), so they set out to regulate it – although it does look strange when e-cigs are banned before they are known to be hazardous, and other drugs and tobacco itself are not banned, in spite of reported harms, lawsuits and vastly expensive health campaigns by the government.

The ironic result of a ban is that all those in New York State who gave up smoking using e-cigarettes are left without their product of choice. Many will go back to smoking rather than abstain completely or take to pharmaceutical nicotine.

Harm reduction must involve some level of autonomy for the smoker.

All this is bad enough. I now refer you to a post entitled 'If you pretend to be doing honest research, don't punish people for believing you'. Paul Bergen recounts the story of a tobacco cessation delegate who was thrown out of a conference for discussing 'harm reduction' as if it meant anything other than compliance with a medicinal nicotine regime. He then recounts his own similar experience. People like Paul Bergen and the other delegate have learned that people who want to stop others from smoking are not working to an agenda that concerns health.

Pharmaceuticals, harm reduction and competing interests

Iro Cyr of CAGE Canada has written an enlightening letter to David Staples of the Edmonton Journal, who wrote an article questioning the delay surrounding new warnings on tobacco packs.

Her letter clearly shows the confusing message put out by authorities that encourage smoking cessation, and yet ban products that customers choose as a substitute, allegedly on safety grounds. The products not covered by such bans include nicotine replacement therapy and other products of pharmaceutical companies. Those that are: e-cigarettes, snus, and other products sourced from companies other than the pharmaceuticals, including tobacco companies. Taking such substitutes off the market in favour of the pharmaceutical companies' nicotine products reduces the options available to smokers who want to stop smoking, and also increases their cost.

Iro Cyr asks why journalists criticise the lobbying activities of tobacco companies but not of pharmaceuticals, for example, who prefer that the only products available to help people stop smoking are their own. The letter is clear and challenging and the links are informative.

The European Commission is currently lobbying on exactly this area in an elegantly entitled consultation: Possible Revision of the Tobacco Products Directive 2001/37?EC, asking respondents whether EU member states should have their own policies or whether policies and bans should be comprehensively applied across Europe. Anyone concerned about the power of the EU should consider answering it, as well as those concerned about effective harm reduction or plain old choice (further details here). Other than harm reduction products (e-cigarettes and smokeless/chewing tobacco), questions cover the display of tobacco, the use of vending machines, the listing of tobacco ingredients and packaging requirements: both whether they should be regulated and if so, whether this should be done on a Europe-wide basis.

Answering this consultation will not be enough, but it will be something.

Three stories make progress

1. Scotsman report on backlash against tobacco display ban: I expected a retaliation from ASH Scotland on Monday morning. It's here! Sheila Duffy reiterates her faith that smoking is the worst thing that could possibly happen to any young person and we are bound to go to any ridiculous lengths to ensure youngsters never even get a sight of tobacco when out shopping (as if that were guaranteed to prevent youth smoking).

2. In A Lesson for Grampian, I pointed out that hospitals in Derby were reintroducing smoking shelters having attempted to go smoke free for a few years. This morning The Telegraph reports on Bournemouth hospitals taking the same action.

3. Finally in Banned from claiming that e-cigs are a stop-smoking aid, I tried to explain the absurdity of official attitudes to the e-cigarette. On the same theme, Tobacco Harm Reduction blog writes: Is parody dead when writing about tobacco harm reduction?