How to resolve a smoking problem: ban e-cigarettes in pubs?

Just a quickie: a headline article in the Evening News claims that Edinburgh Royal Infirmary has 'blown' £600,000 on clearing smoking-related litter since the smoking ban. Clearly this is another attempt to attempt to outlaw smoking on hospital grounds, but to my mind the real question is why anyone has tried to extrapolate smoking-related cleaning costs from total cleaning costs at the hospital. More observations that smoke has been seen curling its way into hospital windows. The way to prevent generalised hostility against smokers on hospital sites is to provide appropriate spaces for people to smoke where they can be comfortable, reasonably safe and won't get in the way of others, but such common sense would be interpreted as an attempt to 'normalise' smoking and cried off the agenda.

Anyone would think that an electronic gadget that produces no obvious waste problems and emits no tar would be a welcome addition to the anti-smoker's apparatus. But the e-cigarette has been widely attacked for not having been proven to be safe: not only concerning their direct use, but there have  been stories abound about e-cigs exploding while being charged, children swallowing cartridges, and doubtless others. Now, incredibly, Borders Council Licensing Board has tabled a motion to ban e-cigarette use in licensed premises. (Stop press: the licensing board has requested more information before agreeing to ban e-cigarettes. I hope they find it's more trouble than it's worth.)

These days there is not even the excuse that most e-cigs resemble real cigarettes and their use presents staff with potential difficulties in enforcing the smoking ban. It's a case of 'they may not be safe', and for some reason this is a reason to ban them. Is it really about normalising smoking? or the idea that people cannot assess safety, even with the help of widely available data?

Official objections to e-cigs versus Forest in debate two months ago here.

'Further indoor smoking restrictions', aka ban on smoking at home

I had a call from the BBC this morning inviting me on to the Radio Scotland Morning Call phone-in with Louise White. The subject was the study blogged by Forest here, by someone at Heriot Watt University here in Edinburgh. It claimed that passive smoke exposure 'in particular in more than two places of exposure was significantly associated with risks of stroke, angina, heart attack, abnormal heart rhythms ... impacted on sleep problems, self-recognition, making decisions, self-confidence, under strain constantly, depressed and happiness in never smokers' (this from the abstract).

Ouch. And to wind up, 'elimination of indoor passive smoking from different sources should still be a focus in future health programs'.

This is surely a case of torturing the figures till their pips squeak. None of the issues in question, including depression and lack of self-esteem, can be attributed to causes as vague as secondary smoke exposure (especially if you experience it in two friends homes in the space of what, a day? a week?)

I wasn't called on to the show until very nearly the end of the discussion, just before 9.30 a.m.. Professor Linda Bauld was on and a medic arguing for further restrictions, and Dr Stuart Waiton from Taking Liberties against it. Stuart pointed out that the new research that comes out all the time always tends to suggest that people's liberties should be further restricted for their own good. Professor Bauld didn't think that legislation would be the answer, but she did want to use what I can only describe as pester power. (It's not enough to open the window or even to go out of the door, you have to go right outside, close the door, etc. I am only surprised that third-hand smoke wasn't mentioned). The medic acknowledged that he would not want to use extra powers to interfere if he thought people were smoking at home in front of kids, but somehow did want something to be done. Callers had varying viewpoints, I think most felt that further powers would not be enforceable (by which I think was meant teachers, health visitors and social workers being able to take action of sorts if they suspect kids are exposed to passive smoke).

My objections to all these restrictions are that the other factors in these conditions they talk of are all vague, nothing is being measured, everything is approximate, nothing is ruled out, and we are expected to accept more or less as a matter of faith that tobacco smoke has the same effect as bad air and damp housing.When I did finally get on air I responded to the point made about this 'new research' recommending more restrictions, by commenting on the neverending flow of anti-smoking studies and by pointing to my favourite page on the Cancer Research UK website. It's the one that says that they fund studies that support existing tobacco policy. (Or to be blunt, they are unlikely to fund studies that don't find a significant risk to health from secondary smoke, or any other excuse to tighten restrictions further.)

Then I had the producer on the line thanking me for my time. By the time I remembered to put up the volume again a minute or so later, they had moved on to a discussion about doggie-bags. Seriously I hope that the national broadcasting station in an independent Scotland will offer something a little more heavyweight!

My views were offered as a non-smoker. I did dabble in smoking a little bit in the early days following the smoking ban. But I didn't miss it when I wasn't smoking.

I was also invited on to the show as a campaigner. Campaigning is not one of my strengths, I am more of a desktop warrior, and it's superficial and non-engaging. Other priorities have taken over (work, mostly) and the group on which this blog bases its name has not really functioned effectively for over two years. I now see the whole issue as one caused by too much centralisation of power generally, and certainly not one that can be resolved by people like me taking on tobacco control directly.

Double standards on child health and smoking in cars ban

Following the decision that smoking in cars could now be outlawed south of the border it was refreshing to see from Zoe Williams in the Guardian some criticism of double standards on smoking. This is the highlight:

Almost all the Tories so fervently against smoking in cars are simultaneously pretty sanguine about foodbanks. Six weeks ago nearly 300 MPs voted against a motion calling on the government to reduce dependency on emergency food aid. It is difficult to observe, without the option of yelling and swearing, how disingenuous this is, how slimy and mawkish for a government happy to live with the idea of people living in squalor, in fuel poverty, going hungry, suddenly to find itself unable to bear the idea of a child in a smoky car.

Williams gets flak from readers about this. It's clearly aimed at all benefiting all kids, not just poor ones and the poor shouldn't be spending their money on cars anyway (or tobacco). But here and elsewhere she points out that Westminster MPs are highly selective in their view of what damages children's prospects and interests.

In perspective: secondhand smoke is implicated in one in five cases of sudden infant death. Since smoke is more intense in a small, enclosed space, it is logical to assume that babies are more endangered by smoking in cars than by smoking elsewhere.

However, the smoking figures are almost always in constellation with other factors – factors surrounding or inherent to the child, from poor housing to low birth weight. Birth weight is of course related to smoking in pregnancy, but again other factors, such as maternal education, age and class, have an impact. A study in Ohio found mould spores in the lungs of sudden infant death victims; and midwives regularly say that mould is dangerous. Kia Stone, a young mother profiled in the Guardian's Breadline Britain series 18 months ago, lost her daughter shortly afterwards. A large mushroom was still growing out of the damp plaster in the bedroom when she got home from the autopsy.

Nobody even collects figures for mould as a risk factor – separate from damp and leaks. Bedrooms that are too hot are also a factor, as is frequent house moving, and living in overcrowded conditions, B&Bs or hostel accommodation. The connection isn't made – presumably through sheer lack of interest – that buildings in which people can't control the heating are often too hot or too cold.

Never take your ability to adjust the central heating for granted! This points to an area of public health (cot death) in which there is no interest in pursuing certain lines of research. When I grew up in the 1970s we were taught that bad housing contributed to poor health, but now the agenda is all about blaming the impoverished for bad choices.

More crudely, is it sensible to assume that what Westminster votes for is aimed to benefit anyone's health? (this question refers not to the general UK population but to its rulers).

Health, safety, toxicology and hypotheses

Hat tip Junican, see comments. In reply to Linda Bauld.

You can't go far wrong if, whenever you see the word 'may' in science, you dismiss the supposition. Science does not do supposition or superstition. It does hypothesis. Scientific investigations MUST depend upon an initial hypothesis. It would be extremely silly to assume that the hypothesis is true, and act upon it, without confirmation of its truth.

The propositions of Public Health are, at the moment, concerning ecigs, ambivalent, and this is a serious matter. There ought to be no such ambivalence.

The mechanical safety of the machine is not a 'health' matter. It is a 'safety' matter, just as electric kettles are a 'safety' matter. The liquids are also not a 'health' matter. They are a 'toxicology' matter. That is, the danger of trace elements in ecig liquid is a matter for scientists in toxicology to decide, and not the Public Health advocates.

Welsh Health Minister wants to restrict e-cigarettes because they resemble a legal product

Because they 'renormalise' and 'reglamorise' smoking, says Mark Drakeford, more restrictions should be imposed on e-cigarettes. In almost the same breath, he mentions New Zealand where these things 'are viewed as health products'. Muddle, muddle, muddle.

Mr Drakeford mentions the addictive nature of nicotine, which the Welsh health authorities don't seem to object to prescribing for pregnant women, only recommending caution. See 'Using nicotine replacement therapy for smoking cessation in pregnancy'. It's not quite clear what their objection to nicotine is, but in any case e-cigarettes are not the first products to offer alternative delivery systems for nicotine.

As it happens I don't object to e-cigarettes being restricted to young people, but the health authorities would be far better advised to let people use them from age 16. That way, they will be able to obtain e-cigarettes legally at an earlier age than they can obtain cigarettes. Given the dastardly character in which tobacco has been painted in the last few years, it's hard to understand what the fuss is about when a product that is thought to be significantly less harmful becomes available.

Do we know that it's significantly less harmful? No? If not, why not?

Economic sovereignty and the freedom to choose

Max Keiser in this video, produced last summer, explains how Gordon Brown MP sold off the UK's sovereignty by putting 60 per cent of its gold bullion on the market below the market price. It's an illuminating talk, and the discussion of UK gold reserves starts about 19 minutes in.



This lecture is a resounding condemnation of current economic policy going back to the Thatcher era, but not letting anyone off since that financial meltdown of an era. It describes generally how interest rates are being kept low because that makes it cheaper for bankers to borrow in order to speculate. This is what enables the financial class to get rich while everyone else lives in fear of a rise in interest rates, because they are experiencing a squeeze on all fronts including housing costs and some people have been also borrowing too. Kaiser predicts that an expected international currency collapse will be particularly hard felt in the UK because of this disastrous sale of gold, leaving the UK without a tangible asset that the rest of the world is buying up.

This affects 'freedom to choose' significantly, showing how little it figures in the calculations of modern-day managers of the UK economy. From a Scottish perspective it heightens my interest in the independence proposition, because the Scottish Government's financial performance has been creditable by comparision. And it makes me wonder how George Galloway can sit through such a lecture and still declare that it is still in Scotland's best interests to stay in the union. He has argued that it is not 'real' independence if Scotland proposes to keep sterling, and this is a criticism that many on the independence side are making, but the sheer savagery of the UK's economic management makes one wonder why anyone would seriously want the Scottish people to stay on board.

'Zealotry plain and simple': e-cigarettes to be banned from Glasgow's Commonwealth Games

So says the Scotsman leader today. The games organisers, after taking advice from the public health community, announced their intention to ban e-cigarettes at the games, having last year announced their intention to ban tobacco.

Public health illuminary Sheila Duffy said:

“The Commonwealth Games will showcase excellence and aim to build a healthy legacy for the next generation. Providing smoke-free environments during events will help deliver on that commitment, and the decision to exclude e-cigarette use should make enforcement more straightforward and also help put the appearance of smoking cigarettes out of fashion.”

And from Health Minister Michael Matheson:

“I welcome this, as e-cigarettes are not regulated, nor have they been proven to be safe and effective.”

This is nonsensical: Matheson's doubts about the 'effectiveness' of smoking are based on the assumption that they are designed as a smoking cessation tool. As an alternative to smoking there is no doubt of their effectiveness. You just put down a roll-up and pick up an e-cig: job done. As to the appearance of smoking cigarettes, these devices appear more like inhalers than cigarettes these days.

These people, especially Duffy, have made a career choice out of the desire to stop people smoking. You would have thought that an anti-smoking sports event would be a lifetime's opportunity to encourage people to quit smoking because 'the single best thing you can do for your health is to stop smoking'. But that's not good enough, because it's not actually enough to stop smoking – you must do so in the approved way.

A Scotsman reader also remarks:

Clever of them to wait until all the tickets have been sold before imposing this ban - and whatever others will be announced before the summer.

For the avoidance of doubt, I don't approve of a smoking ban at the Commonwealth Games either. The public health community only seems to count as public health hazards things that they can blame on the general public: habits, including eating, drinking and smoking. The biggest offender in public health terms is multiple deprivation, and the Commonwealth Games stirred up controversy by accepting sponsorship from ATOS, the company notorious for declaring people of all shades of invalidity fit to work. Clearly there is more to this event than a friendly opportunity to compete internationally in sports, and even the public health community is set on laying unhelpful conditions to participation.

Irish showdown over e-cigarettes shows lack of logic

Watch Clive Bates calmly demolish the logic of tobacco control in the Republic of Ireland:




The anti-smokers describe the need to classify e-cigarettes as medicines and then scratch their heads as to whether these 'medicines' work, when e-cigarettes have never been described smoking cessation medication by their manufacturers (and yet they clearly do work miles better than pharmaceutical alternatives). Kathleen O'Meara manages to suggest that unless smokers use e-cigarettes to give up smoking they are using them simply to 'get round the smoking ban' by using them in places where tobacco smoking is banned – even though no smoke is involved. Far from getting round the smoking ban the smokers concerned are in full compliance with the smoking ban – if the likes of Kathleen O'Meara can't tell the difference between smoke and water vapour that's not the fault of users.

For further remarks see Dick Puddlecote's review.

And more again: Carl V. Phillips explains why the tobacco control community should no longer be able to say 'we just don't know' the effects of e-cigarettes. 

Morning Call, BBC Radio Scotland covers e-cigarette banning, Monday 20 January

It's Monday morning, 9.30 GMT. Gerard Hastings just now saying that e-cigarettes is encouraging people to 'self-medicate on nicotine'. (What is use of nicotine patches if not self-medication on nicotine?) Go here for a discussion for the next hour.

Post-discussion
The official contributors to the programme, Sheila Duffy of ASH Scotland and former Health Minister Andy Kerr, attempted to give e-cigarettes a qualified thumbs-up but seemed hung-up on the idea of renormalising smoking, and, bewilderingly, encouraging nicotine addiction. The bright part was the callers. Caller after caller pointed out that banning e-cigarette use was counter-intuitive to efforts to discourage smoking, and many had been able to give up smoking since they started using e-cigarettes. Some of them were conversant with recent research, and able to compare favourably the numbers of children allegedly using e-cigarettes with those experimenting with smoking.

Two callers at the end who opposed e-cigarette use were particularly unconvincing: one of them pointed out that nicotine was a stimulant and nicotine in e-cigarettes keeps smokers addicted, and the other reported that having given up smoking forty years ago she tried e-cigarettes and enjoyed them. Hence they really should be banned as they are clearly a gateway back into smoking!

The confused kind of consensus to emerge out of all this was that e-cigarettes should be regulated rather than banned. Even I agree with regulation to the extent that (for example) there could be limits on nicotine concentrations for the general user. But there was also talk (by Andy Kerr) of regulating the appearance so that there is a less clear resemblance between the e-cigarette and smoking. Age restrictions might also be beneficial – one could have a minimum age of 16 for purchasing e-cigarettes, which would give e-cig users two years' advantage in terms of legal purchase. By the time they reached 18 they might find the cost advantages outweighed the attractions of experimenting with smoking (unless they were already smoking black market cigarettes of course).

Well done everybody who called the programme. Most of you put the case clearly and rejected the proposition of banning e-cigarettes decisively on the basis that they are an effective and safer alternative to smoking.

Public authorities in Scotland ban e-cigarettes in public buildings

This escalation of banning e-cigarettes does look odd, doesn't it? They are even banned in some outdoor areas around public buildings.

The fear seems to be as expressed by a Glasgow health board spokesperson: 

NHS Greater Glasgow and Clyde said: “The use of e-cigarettes in NHS grounds perpetuates the idea smoking is acceptable in public areas.”

But this approach seems very unscientific. E-cigarette use is not smoking. People are using e-cigarettes instead of smoking, either on a selective basis or completely. After being told more times than most of us have had hot dinners that there is nothing better for your health than stopping smoking, the device people are turning to in their thousands is now facing significant restrictions, and EU legislation still hovers over them.

The only thing that needs to be done is regulation. Tobacco is regulated, and all consumer products require some regulatory oversight to protect consumers. There is no call whatever for a ban.

Health authorities who ban e-cigarettes because they make users look like smokers should take a good hard look at themselves. Having derided tobacco companies for the alleged health records of smoking for over 30 years, it seems perverse to ban the use of a product that can eliminate the most hazardous elements of smoking, namely the absorption of tar and smoke. If smokers can use this product at less than the cost of smoking, they may not return to smoking.

Anti-smokers have little to be complacent about. Illicit tobacco is becoming more plentiful on our streets, and can remove any price advantage that the less harmful product has.

Scottish public authorities need to get a grip on themselves. They provide a valuable service but they are not (or should not be) empowered to pronounce what recreational products the public should find 'acceptable'; or to assert ownership of 'public areas'.

Bafflement on devolution from Scottish tobacco control

The bit of Sheila Duffy's letter that I don't understand comes right at the top.

JORGE da Motta of JTI claims that devolving powers on tobacco duty to Scotland could harm our economy (“Tobacco chief fires up debate over duty”, News, 5 January). But World Bank reports show clearly that tobacco is poor value to any economy, on economic as well as on health grounds, as the diseases smoking causes cut down many in the prime of their working lives.

She's writing a response to the article here. But the article doesn't say that JTI says that devolving powers might harm our economy. He warns that the wrong policy choices will bring about more bootlegging – not the tobacco duty, but failures in policy-making, which will lose the Scottish government money. So apparently Sheila claims that JTI fears that tobacco duties will somehow ruin the economy, and contrasts this with the World Bank view that tobacco is poor value to any economy.

Not a lot of contrast there. Perhaps Sheila has been the victim of a bad sub-editor.

I was hoping for some enlightenment on the finances of post-devolutionary Scotland, but I'll have to go elsewhere!

Professor John Britton's UKNSCC conference address supporting e-cigs, summer 2013

Having predicted that e-cigarettes will destroy tobacco control I decided look further for signs of hostility on the part of major tobacco control players towards e-cigs. I started with Professor John Britton, a leading light in the UK Centre for Tobacco Control Studies.  Professor Britton spoke in favour of the motion 'The field should be positive about the development of e-cigarettes' (the only part of the debate that seems to have been recorded). His opposer was Jean King of Cancer Research UK. The debate is accessible from this link and includes a slide presentation.

The debate addresses tobacco control's fears that tobacco companies use the e-cigarette market in e-cigarettes to buy respectability and even a place at the public health table, from which the tobacco industry is excluded.

I have to admit that Britton surprises me in some ways in this address: first by describing the non-medical nature of e-cigarettes as a 'strength'. He sees it definitely as an asset that smokers are using e-cigarettes heavily. His evidence tells him that smokers use them overwhelmingly as a tool to stop smoking, and in general he is in favour of them.

He also points out the involvement of pharmaceutical investment in the smoking cessation conference itself, and notes that pharmaceutical investment is an accepted part of life. Not only does he ask whether it is acceptable to take money from pharmaceutical companies and decline it from others, he goes so far as to point out that pharmaceutical companies have in some respects a murderous safety record. (I'm now trying to work out exactly what he means by this: surely not that tobacco money is acceptable?)

As to whether the tobacco industry's involvement should be a cause for alarm, he illustrates deftly how hard it would be to advise smokers against specific electronic products, because ownership and investment in these by tobacco and other companies shifts all the time. The key, he concludes, is to regulate the product, not the manufacturer. I'd love to hear Jean King's case against this, indeed the rest of the debate.

Britton's closing slide shows a technician at his university who has stopped smoking 'on his own' with the help of an e-cigarette. The technician doesn't want him (as a tobacco control policy leader) to interfere with the flavourings. It seems clear that at least some professional tobacco control practitioners feel ownership of this new tool in the box that they can use to help people stop smoking. But the technician, using the e-cigarette, has not needed Britton's professional help.

If anyone knows whether the rest of the debate was recorded I'd love to hear it!

Use e-cigs in the fight against tobacco, says former ASH director

My attitude to the smoking ban is unchanged: I still believe it is step too far, especially when since it was based on a phenomenon (secondary smoke) that I regard as highly speculative.

But I am now interested in the e-cigarette issue. There can be little doubt that e-cigs are the bastard child of the two warring parents: tobacco and tobacco control. The child has now taken on its own identity and has many of its own friends. Had tobacco control not come along, e-cigs would not, so to speak, have been conceived at the time that they were. Not only have they satisfied the demand of an alternative to smokers that is acceptable on health grounds – no tar is inhaled into the lungs, but they have done so by avoiding the much feared smoke that is a product of smoking tobacco.

Tobacco control can huff and puff but a paternity test would probably prove my suggestion that the e-cig is its own doing. Legitimate health concerns followed by a virulent campaign against smoking (that continues even now) have provided the incentive to produce a product that smokers can enjoy without bothering anyone else.

Committed smokers fear that the e-cigarette will be 'forced' on them and I hope that they are mistaken. I would still like to see the smoking ban rescinded. But the reason e-cigs are interesting to me is that they are an effective alternative to smoking, meaning that we don't really need tobacco control any more. Action on Smoking and Health has a mission to fight 'the harm caused by tobacco', and, with e-cigs, much of the problem is resolved.

Among the good things that former director of Action on Smoking and Health Clive Bates says in this piece (a Rapid Response to the piece discussed here) is that he scolds tobacco control for its inveterate hostility to tobacco companies:

Negativity about the tobacco industry is inevitable and appropriate, but there has long been scope for a different business model to emerge [8]. Many in the public health community regard the industry as, a priori, capable only of causing harm as they strive to make money [9]. But this idea is not universally accepted, and there are different ways of looking at the role of tobacco companies when it comes to ‘harm reduction’ [10]. ... Big Tobacco is moving into e-cigarettes because it has to, not least because its customers may want nicotine, but increasingly they don’t want the smoke that goes with it. Meeting that changing demand happens to be a very positive one for public health, and it could ultimately change the tobacco industry itself for the better.[emphasis added]

I am not sure whether Big Tobacco is actually capable of becoming a significant player in the e-cig market, but the point is that Clive Bates (and many others) can see beyond the caricature of Big Tobacco as irrevocably and completely evil. Another dynamic is possible.

Tobacco control has allowed its hatred of tobacco companies to present a conflict of interest with its own health goals. Every time it declares a wish to destroy tobacco companies it takes its eye off the ball of public health improvement, preferring to focus its attention on winning a war, on destroying an industry. Is this a bid to improve public health, or more to gain market share for nicotine-based cessation medications?

I haven't seen smokers' groups forming themselves to discuss the merits of nicotine patches. This phenomenon has occurred with e-cigs: there is a market of people who are actively interested in the product, which has evolved to become affordable.

OK, perhaps I am daydreaming a little with the fantasy that e-cigs will finish off tobacco control. But if all it can now do is to try and frighten users away from e-cigarettes, what will it then achieve? 'The best thing you can do for your health is to stop smoking': this logic has to remain the purpose of tobacco control. It cannot now shift the goalposts and insist on the right to dictate to users how to stop smoking. That horse has left the stable and e-cig shops are everywhere.

It may be that tobacco control can survive by taking on the cause of e-cigs, but I am not sure how that would stack up financially. I am sure that some of their revenue stream must come through pharmaceuticals but I haven't figured out exactly how it works. I expect to see tobacco control continue to insist that patches 'n' Champix R best, digging itself deep into its own grave as it does so.

Scottish Government welcomes JTI intervention on tobacco duty

Has to be true because I read it in the Scotsman! Japan Tobacco has pointed out that post-Independence the Scottish Government will receive tobacco revenues directly, and speculates that it might think twice about bringing in policies that might jeopardise revenue receipts.

I have to put this in context a little. The suggestion is that the Scottish Government will get revenue-raising powers even if Scotland doesn't go independent. I am still not sure why Westminster would want to encourage devolution of tax-raising powers if the vote is no, because it would allow more divergent economic policies to develop than we have at present – surely the kind of scenario that Westminster rejects when saying that sharing a currency with an independent Scotland wouldn't work.

The Scottish Government clearly want a situation with more tax powers, and in fact I agree with them – it is right that Holyrood should have the responsibility for raising revenues as well as spending them. (I also agree with them that they are unlikely to be able to exercise responsibility fully in a devolved Scotland, but that's not really the point of this article.)

The purpose of the JTI intervention is to sound a warning shot about the Scottish Government's plans for plain packaging of tobacco. I am not aware of any certain evidence about plain packaging deterring youth from smoking. There has been a lot of speculation, but no hard evidence.

I can speculate too, and my speculation is that criminalising the branding of tobacco removes a tool for consumer protection that is designed to reduce counterfeiting, and is likely to result in a race to the bottom in tobacco prices. If such a move is backed by further increases in duty, the illegal market will grow even faster than it is growing currently.

Both these moves will be bad for government smoking cessation plans – for its heralded ambition to make smoking history by 2034 – and for its treasury coffers. Treating e-cigarettes in the same prohibitive way as tobacco, rather than as a probably harmless alternative, will aggravate this effect.

The Scottish Government's comment?

The intervention on devolving duties has been welcomed by the Scottish Government.

A spokesman for First Minister Alex Salmond said: “We welcome all backing for transferring responsibility for duties and revenue to Scotland.

“Only by having control of these key levies can we take forward policies designed to protect public health and boost the Scottish economy.”

They'll have to mull that one over before it's time to produce the first post-Referendum election manifesto.

The BMJ, e-cigarettes and Scotland

The British Medical Journal clearly expects Scotland to lead on its crusade against e-cigs, as it did with the smoking ban and in the way it has not blinked in its pursuit of plain packaging of tobacco. Fiona Godlee, BMJ editor, declares that the Scottish Government's ambition to end smoking by 2034 will go pear-shaped if it does not take a firm line with tobacco. The Scottish Government along with ex-Mayor Bloomberg of New York earn brownie points with Godlee for taking stern measures against food, drink and tobacco and the paper turns on Bloomberg's action in banning indoor use of e-cigarettes before leaving his post recently. (Godlee uses the word 'smoking', although  you would be no more likely to get smoke out of an e-cigarette than you would out of your kettle.)

There is some unhelpful argument here along the lines of tobacco being normalised by the popularity of e-cigarettes, and it seems based on the assumption that tobacco companies are a significant player in the e-cigarette economy. She says, 'E-cigarettes also legitimise the industry, buying tobacco companies a seat as “partners” at the health policy table'. Not only is this untrue (at least in the view of Rose, quoted here), it is also quite irrelevant to health policy.

Another plank of her paper is asserting that the BMJ will not reverse its decision to decline publication of papers that have been funded by the tobacco industry. This is a related error. The veracity of papers is determined by its content: funding is a consideration, which it is why it is declared, but funding does not determine accuracy or otherwise. Tobacco companies are legal entities and players in the market place and there is no reason to dismiss them from public debate, which exists to allow the weighing of different perspectives against each other. Health policy is another arena in which tobacco companies have a contribution to make (balanced by other interests, obviously); Godlee allows her position that tobacco companies have no place in health policy to influence her view on whether e-cigarettes are a beneficial alternative to smoking. This seems to me to be a conflict of interest, since her desire for tobacco control interests to dominate the health policy arena over-rides the health concern. If this results in the banning of a safe alternative to smoking when medicinal alternatives fail to work, there is at least potential for severe adverse health reactions.

As far as Scotland goes, so far they have backed the UK as shown in this Parliamentary motion published last June:

Motion S4M-06979: Stewart Maxwell, West Scotland, Scottish National Party, Date Lodged: 12/06/2013

New Restrictions on Electronic Cigarettes

That the Parliament welcomes the decision by the Medicines and Healthcare Products Regulatory Agency that electronic cigarettes (e-cigarettes) will be licensed as a medicine in the UK from 2016; understands that the new classification will assist in ensuring that the promotion of these products to children and non-smokers is prohibited; regrets however that this decision will not be implemented for a further three years; believes that any change in the classification of e-cigarettes should ensure that they are sold only by appropriately licensed premises; highlights that e-cigarettes are currently unregulated and the associated potential health risks are unknown, and encourages smokers to take the advice of the British Medical Association, which directs patients to regulated products and licensed nicotine replacement products to help quit smoking.

 *S4M-06910 Stewart Maxwell: The Scottish Directors of Public Health and E-cigarettes—That the Parliament welcomes the position of the Scottish Directors of Public Health (SDPH), which, it believes, has strongly advocated that NHS policies on tobacco should treat electronic cigarettes (e-cigarettes) the same way as normal cigarettes; understands that SDPH has claimed that the use of e-cigarettes in NHS grounds perpetuates the idea that smoking is normal behaviour and acceptable in public areas; believes that the potential of e-cigarettes as a tool in harm reduction and the risk that they pose to health and safety is still to be determined; notes that smokers who wish to quit can use evidence-based nicotine replacement therapy products and contact NHS Smokeline to find out further information, and urges them to use one or both of these approaches instead.

This shows that the party leading Scotland to independence in the referendum this coming September has a steep learning curve on the subject of e-cigarettes. Vapers in Scotland should renew their efforts to brief parties that support the independence project with their concerns about regulating e-cigarettes, especially in the event of a yes vote. (In the event of a no vote I predict that not much will change, because Westminster is top-down rule.)

Vaper challenges Australian charity on its opposition to e-cigs

I make no apology for including this in the blog although I know that some readers may wince at the bad press that e-cig enthusiasts might give smoking. The point here is not about whether smoking or e-cigs are bad for you, however, it is to show what is obvious to vapers – namely that proposals to ban e-cigs illustrates more effectively than any other measure that tobacco control is about anything but health.

Vapers might give tobacco and smoking a bad press, but in general I have found little sign that they agree with the banning of tobacco or institutionalised stigmatisation of smokers – of course there are many bad apples in the barrel who like to mouth off in online comments, but let's look at this rationally. They have found an alternative to smoking that works for them, and then find that the health authorities wish to ban their preferred solution to the smoking issue. They find that the health authorities don't want them to help themselves but to accept help from official channels that is worse than useless and guaranteed to keep many would-be quitters smoking.

This makes a grim picture: not of health authorities that work for the good of health, but of health authorities that work to an agenda that is not altogether clear, but one suspects is contaminated by authoritarianism and perhaps commercial considerations. Who knows, but anyway it's contaminated by irrelevant factors. There is a discussion here about it between Rose (a vaper) and Terry of the Cancer Council of Western Australia. Rose has written an angry letter to the CCWA and now writes, more calmly, to counter Terry's response.

The main points: (1) Terry, writing on behalf of a cancer charity, does not mention cancer in relation to e-cigs, yet his organisation calls for an e-cig ban. Why does he want to ban a product that has not been linked to cancer? This goes beyond the remit of his charity. (2) In common with other authorities wishing to restrict e-cigs, Terry refers to e-cigs as smoking cessation tools, whereas they are in fact an alternative to smoking – recreational products, not medicinal or therapeutic ones. The law that Terry wants to use to ban e-cigs is called the Therapeutic Goods Act, and it does not cover recreational products. (3) Contrary to Terry's assertions about the ineffectiveness of e-cigs 'as smoking cessations tools', Rose points out the enormous popularity of e-cigs and internet presence in the form of user discussion groups. They are truly an alternative to smoking popularised by users rather than by those claiming to act in their interests. (4) Terry recommends conventional smoking cessation medications, as further proof that he is not paying attention to people's preference and experience about what works for them. (5) To Terry's concern about the long-term effects of e-cigs, Rose offers herself as a medical guinea pig, in the meantime pointing out the documented differences between conventional tobacco and e-cigs in terms of carcinogens and other toxins.

Rose compares the CCWA's head-in-the-sand approach to e-cigs as follows:

an organisation such as a Cancer Council failing to notice the current storming of the tobacco market by e-cigarettes, is like the Australian Bureau of Meteorology failing to notice the formation of a Category 5 cyclone just off the coast of Queensland.

I think the observation is apt. (I hope that e-cigs will also help to destroy what remains of tobacco control – at least its worst excesses, and there are very many of these.) She also says:

Those of us who use these products generally experience a profound gnosis that the era of smoking tobacco is coming to an end. Ecigs are to smoking what the motor car was to the horse and buggy.

You may or may not agree with this. But it is a prediction of a trend, not an avowed intent to destroy the tobacco industry. Elsewhere Rose states:

Tobacco control is one thing. Placing prohibitive taxes on smokers, defacing their packaging with theatrical disease pictures, and concurrently preventing them from accessing a safer alternative does nothing but serve the lust for vengeance of anti-smoking zealots, and drive more and more smokers to the black market. The recent KPMG report shows that illegal tobacco sales have risen from 1.4% share of the overall market to 10.4% in a single year.

The argument has moved away from the tedious issue of whether passive smoking causes cancer or not to what the hell is tobacco control up to, actively trying to prevent people from looking for their own preferred alternatives to smoking. They say 'the best thing you can do for your health is to stop smoking', but when people take this advice they are hampered and told they're doing it wrong. This is a sound and well researched argument – well done, Rose!

Tobacco control in the Gulf states

I picked up this story this morning from the Framework Convention Alliance news feed: Saudi Arabia enforces crackdown in shisha cafés in Eastern Province.

I can't help wondering how much good it does the tobacco control cause to associate itself with an authoritarian regime that makes use of the death penalty and flogs people, doesn't allow women to drive, doesn't allow public worship of any religion but Islam, and so on. The Saudis wanted to stop Russia from supporting Syria too, incredibly falling into line with Israel in the Middle East battle lines. Isolating Syria from its alliance with Russia could have led to war, giving rise to some wonderful health outcomes.

My last blog post touched on this: the importance of central control in the tobacco control model. I think it's partly why I am drifting away from the tobacco control debate (which can get a little repetitive after eight years) and taking more interest in how we are governed. It certainly feels odd that in both Saudi Arabia and Scotland concern for people's health takes the form of fighting tobacco, and the same applies south of the border, when we have so little else in common.

Local choice and democracy: normal life versus tobacco control

How local is democracy? This question arises in relation to the news that elections to local health boards will not now occur, as reported by columnist Lesley Riddoch here. (Her recently published book Blossom covers similar arguments.)

She talks about how to make Scotland blossom: how to arrange matters so that far more of its population can access its natural resources. One major point of comparison is that 'local' in Scotland is fairly meaningless, considered in the example of, say, Strathclyde or the Highland Region, where populations under regional administration are vast, as is the area covered. 

Every way you measure it, Scotland is doing badly. In Norway, with genuinely community-sized, tax-raising municipalities of around 14,000 people, election turnouts range from 70-82 per cent and one in 80 Norwegians stands for election. In Scotland, community councils have a tiny average annual budget of £400 and no statutory clout and services are provided instead by large council bureaucracies for an average 162,000 people. These “local” councils receive most of their cash from central government. Turnout in the 2012 elections was 38 per cent and one in 2,071 Scots stood for election.

I am just reading another book about how multiparty democracy and proportional government make for a greater diversity of political parties, and the paragraph above goes some way to explaining why this doesn't seem to happen in Scotland. More centralised administration yields fewer parties, lower political participation, and lower living standards generally. Scotland is far from being the worst governed country in the world, but it seems to have much to learn about increasing democratic participation.

If Scottish democracy is characterised by a shortage of public representatives below regional council level, ASH Scotland represents a stark contrast in its flow chart illustrating the Scottish Tobacco Control Alliance. This is top-down stuff, but they are organising the whole country into tobacco control groups at all levels. (All right, not quite the whole country.) Topic groups, smoking cessation groups, working groups, member organisations, overseen by the SCTA, ASH Scotland, and further up the tree the European Union, the UK government, the Framework Convention on Tobacco Control (FCTC), and overall the Scottish government 'involving the tobacco control community in developing and implementing policy'.

It's an impressive level of networking, but it should not be top-down, and is crushingly narrow in its outlook. We have huge problems in our country of chronic ill health, poverty and under-representation, but the answer seems to be – just don't smoke.

Even people who do support certain tobacco control initiatives should worry about the centralised nature of this drive for greater tobacco control which is entirely centre funded, has tentacles throughout and beyond all health boards and is mirrored by the absence of any real local democracy.

More enormous settlements from drug companies

I heard this story on BBC Radio 5 last night and thought it would be everywhere today but I've had to look for it.

In the face of this kind of story I really don't understand why such a fuss is made about tobacco companies covering up evidence that their product is harmful. Since people inhale tobacco smoke into their lungs and quite often feel ill the first time they smoke, tobacco itself is not generally expected to help improve people's health. Even before the days before tobacco control could afford to studies week after week telling us (again) how dangerous smoking is, there can be few people who seriously believed that their health was not at some risk in the medium to long term as a result of smoking.

Only last year GlaxoSmithKlein and now Johnson & Johnson and subsidiaries have now settled multi-billion dollar lawsuits on the grounds of fraud. For companies of such stupendous size and with such stupendous drugs to market drugs for uses other than those that they were designed for should be a matter for criminal liability:

In its plea agreement, J&J subsidiary Janssen Pharmaceuticals admitted that it promoted Risperdal to nursing home doctors and nurses to control erratic behavior in seniors with dementia between 2002 and 2003. ... 

In a separate civil complaint, the government alleged that J&J and Janssen also promoted Risperdal and a similar drug Invega, to control numerous behavior problems in seniors, children and the mentally disabled between 1999 and 2005.

Not only did the charges relate to unlawful marketing, but also the targets were patients whose capacity to understand what they were being prescribed was limited. The report says that the purpose was 'controlling behavior problems', but this involves messing about with brain chemistry and should not be done using the wrong drug (even using the 'right' drug is probably questionable in many cases).

This seems an unforgiveable breach of professional practice. People are entitled to expect better health from prescription drugs in a way that is simply not true of tobacco.

This settlement goes back to cases that took place nearly fifteen years ago. Clearly the profit imperative is very strong in the pharmaceutical market. Somebody will no doubt say that this is a 'few isolated cases', whereas the whole of tobacco is suspect. But it should not happen with pharmaceutical drugs at all, and more importantly tobacco does not set out to be medicinal.

Do as we say, not as we do on addiction

The British Medical Association has advised Celtic and Rangers to cut its ties with e-cigarettes. The clubs now both have links with E-Lites, enabling the e-cigarettes to be sold and used at matches.

Clubs have been persuaded to enforce the smoking ban at matches, even though a substantial number of fans are not standing or sitting under cover during matches. They have bought into the idea that smoking should be avoided at any cost, an ambition that e-cigarettes have attempted to capitalise on.

The clubs and companies have together formed a partnership to allow people access to a product that allows an experience mimicking smoking to be carried out at matches. It might even make the difference between some fans attending or not attending matches, But their anti-tobacco stance does not satisfy the BMA, which is interested only in complete cessation or pharmaceutical alternatives to smoking, because anything else 'encourages addiction' (why e-cigs do this more than nicotine patches is anybody's guess.

Two readers' comments seem quite apposite:

Is this the same BMA that is quite happy to give methadone to opiate misusers as it "lowers the death rate"?

The other appears in an earlier version of the story, announcing the double deal between E-Lites and both Rangers and Celtic (Herald, free registration required):

The MHRA says ecigs will be regulated as medicines in 2016 with all flavouring to be banned and strengths to be limited. It's spokesman Jeremy Mean says that no current devices would would gain medical approval (even if the importers could afford the million pound cost of licensing their device). Now ecigs have the backing of huge businesses such as Celtic and Rangers, it will be interesting to see whether the MHRA persists with its policy – a policy likely to result in tens of thousands of extra future lung cancer deaths when people find the approved devices, ironically likely to be owned by tobacco companies, unsatisfactory and switch back to tobacco [emphasis added]

The idea that medics are anxious that the economic power of Rangers and Celtic might ultimately dilute the MHRA decision on e-cigarettes is sadly believable. It makes one wonder if giving up smoking is as high up their list of priorities as they would have us believe.

Far from not wanting people addicted, it looks as if all parties are anxious to make money out of addictions, even if only to prevent their evil competitors from making money out of addictions instead!