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.)

Rather hopeless endgame vision contrasted with the view from the ground

Yet again the New Zealand government has declared that commercial sales of tobacco in New Zealand will cease by 2025. The most recent edition of Tobacco Control actually contains a section called The Endgame, which includes this beauty: How smoking became history: looking back to 2012. Here's a taste:

Of course, designing viable and effective policies is a matter partly of logic but mostly of trial and error. The cap reduction proved too complex administratively. Bhutan banned the sale of tobacco products in 2004 - but almost no one noticed!13 New Zealand went for a ban in 2020, which went so smoothly that many countries followed suit with much shorter lead times. Those who had been worried that a country adopting a ban would need, like New Zealand, to have ocean on all sides were reassured when the smoking rate dropped below 10% even before the ban took effect: it turns out that so long as cessation assistance, including a variety of non-combusted nicotine delivery devices, is available, along with regular tax increases and a focused media campaign leading up to the ban, there is little residual demand for smuggled cigarettes. 

Singapore went ahead with a ban on sales to anyone born in the 21st century. This was adopted in 2012 near the time the World Conference on Tobacco or Health was held there. There is obviously no peer pressure for young people to smoke, and the few remaining older smokers get the pity they deserve. A few other countries jumped on the 1999 cut-off date; later arrivals have used dates early in the first decade.

Easy, isn't it? I am actually quite taken aback that the BMJ has taken to publishing this kind of futuristic nonsense in Tobacco Control, which is meant to be a professional journal. It shows complete blind faith in its ideals and no notion that anything resembling an unintended consequence might imperil its ill-thought-out plans.

Back in the real world, grocers point out that there is already an enormous amount of non-duty paid tobacco being sold in the street.

Website author of Tichtich discusses illicit tobacco and the supply chain in more depth:

What this study confirms is the weakness of official statistics on the number of people who smoke. These are compiled from official sales figures together with a reasonably sensible guess of the number of legitimate personal imports under EU trade rules (thee and me bringing back our 16 cartons) and a rough guess based on the number of seizures of illegal cigarettes. Before this investigation they put the figure for illegals at less than 5% for the UK as a whole. Clearly their statistics are wrong, hence much of the so called "progress" made with smoking cessation is little more than wishful thinking. 

As an aside, it also rubbishes the notion that smokers are loyal to a brand. We couldn't care less about the brand, it's the price/taste of the thing that matters. Furthermore, to avoid the diseased photographs or foreign script, an increasing number of smokers never carry their cigarette packets, preferring to use a cigarette case. These packs go for recycling along with the rest of our cardboard. Market penetration is actually far greater than even these figures indicate.  

Trouble is the folk employed to run up all this information are several steps removed from what goes on in real life. They're unlikely to frequent the less desirable areas of towns, they're not part of the smoker experience and they're less likely to strike up casual conversations with us outside offices, shops, railway stations and beer gardens. Those who do all these things are not only aware of whats going on with cigarettes and tobacco of questionable origin, we also know that official statistics on youth smoking are similarly wide of the mark.

I make no apologies for finding this version more credible.

Stirling University research on plain packaging

Is this study what all the fuss was about? Dear oh dear.

'Nearly 50 young adult smokers used non branded cigarette packets in everyday situations for two weeks.' The smokers were less keen than those in a control group to hand out cigarettes or have the packets on show. The researchers didn't take into account that if plain packaging were everywhere, people would be less self conscious about using tobacco in public places – bearing in mind that there is nowhere comfortable to do it publicly anyway. Admittedly this is only a report of the study (available in full to subscribers of the British Medical Journal) but no attempt is made to explain whether the subjects' smoking behaviour changed in private.

The research is also reported in the Scotsman here. This report focuses on 950 children interviewed during the study. Again with the proviso that we are looking only at a report of the study, some findings are quite breathtaking – for example:

It claimed 27 per cent of the 950 people questioned were susceptible to taking up smoking in the future because they failed to express a definite desire never to smoke. 

The people conducting this study seem a little out of their depth. Many people drastically change their expectations and preferences quite drastically between their teens and adulthood, often to their own surprise.

Dr Crawford Moodie's assertion that 'the study confirms the lack of appeal of plain packs, with the enjoyment and consumption of cigarettes being reduced' can be described as wishful thinking, based on the fanciful idea that smokers enjoy smoking because of the attractive packaging. 

This is the current line-up on the BMJ's Tobacco Control periodical. In addition to Crawford Moodie's piece there is an editorial on plain packaging.

Tobacco pharming

When is a tobacco company not a tobacco company?

The WHO, FCTC, EU, national governments and the anti-smoking lobby, as per article 5.3 of the Framework Convention on Tobacco Control, refuse to sit round the table with tobacco companies yet quite happily accept representation from Pharmaceutical Companies. The question that must be asked is "What is the difference when Big Tobacco and Big Pharma are working together?"

The company annual report for 2010 shows that Japan Tobacco International has an R&D section which has worked on producing drugs to combat osteoporosis and HIV and that licences have been agreed with Pharmaceutical Companies both inside and outside the USA. Companies include GlaxoSmithKlein, Roche, Merck, Torii, giving a global reach.

Clearly tobacco companies will not be chastised if they get involved in pharmaceuticals, because pharmaceuticals are an approved activity. (Nor will the pharmaceutical companies which collude with companies that are engaged in pharmaceutical research – even though the likes of Japan Tobacco is still involved mostly in tobacco.) 

Article 5.3 seeks to 'protect health policy with respect to tobacco control from commercial and other vested interests of the tobacco industry'. This means in the ideal world of tobacco control, the tobacco companies don't get a look in, and despite their products being very highly taxed are expected to be listened to politely and dismissively without any hope of being able to influence the outcome in tobacco or health policy. The same applies to anyone who sells or distributes tobacco (those involved in tobacco vending machines are endangered and soon to be extinct).

So if the tobacco companies turn their attention to medicinal drugs will they be invited back to the table? because they won't have an axe to grind in the pharmaceutical area of their operations. To paraphrase the British Medical Journal, 'an obvious escape from this negativity is to quit the tobacco market'. 

Personally I think it's highly questionable whether overloading the pharmaceutical market is necessarily beneficial to health, and in general I would prefer a business environment where investment decisions were not guided by government-sponsored vilification/denormalisation/negativity campaigns ... whatever you choose to call them (and Simon Chapman and Becky Freeman, writing in the British Medical Journal, couldn't have described the process better if they were trying to slander themselves). 

Anti-smokers struggle to keep up

For the second time this week, anti-smokers have made an unseemly fuss about dreadfully old news. The first was when the BBC was criticised for this. Written in 2001, clearly headed with a disclaimer, it raises the wrath of doctors in 2011, as reported here.

Now the British Medical Journal (keeping its mind on serious medical issues as usual) has a go at tobacco companies because they have taken to selling cigarettes in packs of 14. Yes, packs that have been in circulation since pre-historic (i.e. pre-smoking ban) days have just reached the attention of those doctors insane enough to complain about such trivia.

Campaigners are outraged that smokers can buy cigarettes in packs of 14 'instead of the usual 20'. Should I add to their consternation by reminding these worthy campaigners that smokers can still buy ten-packs, as they didn't get round to banning them yet?

The vested interests of (ahem) tobacco companies, and private meetings

This month Ms Duffy blogs on the Guardian's revelations that tobacco industry funding had assisted newsagents in their campaign against the display ban, covered in a story here just over a week ago.

ASH Scotland's concern with tobacco industry 'vested interests' is natural. Any industry has 'vested interests' in public policy debates that affect its products. Less wholesome are 'competing interests', especially in the field of tobacco control: this is where a lobbying group claims they are acting in the public interest, even though private interests benefit from their lobbying activities. Even the British Medical Journal published a note of concern about this issue.

Ms Duffy also refers to a meeting that was 'publicised' by the Scottish Licensed Trade Association, where 'retrograde moves' and 'backwards looking, expensive and unworkable' proposals were discussed – the whole thing financed by tobacco companies. Simon Clark has quite rightly pointed out that not only was the meeting private, but also funding it was a matter of necessity. Publicly funded Ms Duffy with no anxieties about her next meal (cool salary offered here, and it's not even the top job)  huffs about tobacco money going to fund private trade meetings on topics vital to their commercial survival.

Interesting that with this kind of track record, pharmaceutical companies – the ones who feed the tobacco control industry – are regulated with such a light touch in Scotland. Incoming MSPs take note.

WHO demands general smoking ban in Germany

It is harder now for European authorities to claim that smoking bans are universally popular. Germany has failed to enforce its ban, Spain has protested vigorously, and Belgian café proprietors and customers have also protested about a ban due for implementation in food establishments on 1 July, three years earlier than planned. The Netherlands has also thrown off its ban for bars without employees.  


Demands not just for a full implementation of the ban in Germany but for the law to be enforced centrally instead of in its federal states have appeared, of all places, in the British Medical Journal.  I only have access to the abstract but already the Heidelberg branch of the World Health Organisation gets its say, claiming that the German people are exposed to dangerously high levels of smoke in their restaurants and pubs.


(Clearly he seems to be under a misapprehension that people are forced to allow smoking in pubs and that unwilling customers are forced to go into them.) 


People seem happy to tell priests to keep out of politics and stick to religion: not a view I would necessarily agree with – everybody should have a say in politics. I would only agree to limiting religious interference in politics if religion wanted to keep secular interests out of politics. Why don't people realise that health is the new religion? Why do people tolerate health officials who are so steeped in politics that they happily recommend interfering with German legislation in order to achieve their smoke-free agenda? 


The study is entitled 'Full smoking ban is needed in Germany as four out of five pubs flout regulations'. What size of budget is needed to report what is common knowledge: that people can smoke in German public houses? 


The Netherlands didn't get off scott-free either. Tobacco control has no respect for national boundaries. 

Denormalisation: 'an obvious escape from this negativity is to quit smoking'

So says a 2007 BMJ report (Australian) about denormalisation and smoking: bear in mind that this is a publicly funded study. Entitled 'Markers of the denormalisation of smoking and the tobacco industry', it delinates some of these 'markers', such as: 

Smokers as malodorous
Smokers as litterers
Smokers as unattractive and undesirable housemates
Smokers as undereducated and a social underclass
Smokers as excessive users of public health services
Smokers as employer liabilities

(h/tap Rose for this neat summary, writing on Frank Davis's column). So much for smokers: and let nobody say in future that this is about denormalising smoking, as opposed to smokers. This is the horse's mouth. This section describes the ways in which a denormalisation campaign seeks to portray smokers ('smokers are framed as mindless, almost criminally anti-social polluters'; 'recent public debate about whether smokers should be given lower priority than non-smokers in surgical waiting lists or even denied elective surgery paid for by the public health system have drawn on implications that smokers are somehow unwilling to assist in improving their own prognosis').

As for denormalising tobacco companies: universities will not accept funding from them, credit card companies and courier companies have ceased involvement with internet sales of tobacco, and so it goes on. Tobacco companies have been spurned by ethical investment companies and promoters of Corporate Social Responsibility.

The paragraph on negative consequences asks the pertinent questions: 

Are smokers less likely to seek medical help due to public debates around whether they “deserve” medical treatments? Will they feel ashamed when doing so, adding to their stress and perhaps prognosis? Are smokers unreasonably discriminated against in the workplace, even when they do not smoke indoors and put others at risk? [emphasis added]

But it continues by quoting a referenced paper by Bayer and Stuber: 'policies and cultural standards that result in isolation and severe embarrassment are different from those that cause discomfort … Acts that seek to limit the contexts in which smoking is permitted are different from those that restrict the right to work, to access health or life insurance, or to reside in communities of one’s choice' [emphasis added]. If that isn't moral equivocation I don't know what is.  A 'utilitarian calculus' must be applied, whatever the hell that is. (If it means benefiting the greatest number I couldn't agree more but they got it wrong because they forgot to include the smokers who don't want to stop smoking when told to.)

In conclusion, the markers of denormalisation are meant as a measure of the progress of tobacco control in different localities. Since its authors promote tobacco control, they commend these markers and recommend their regular reporting and analysis. Their inherent purpose is to demoralise and marginalise a specific group in society. The smoker's only possible recourse is to stop smoking (see title of this post): they see smoker cessation as intrinsic to their goals:

For governments, this negativity foments a public climate that is highly receptive to tobacco control legislation, polices and programs. We would argue that there is a dynamic, synergistic relationship between formal tobacco control interventions and policies, falling smoking prevalence and the increasing range and growth of the markers we have listed.

Would they acknowledge failure if the numbers of smokers were unquestionably shown to increase, revealing the propagation of denormalisation and victimisation as an activity limited to zealots?

The paper was funded publicly by the Australian Government, and has to be among the most appalling I have ever read. In its war against tobacco companies, Tobacco Control declares that its manifesto is demonising and lowering tobacco users in the eyes of the public and states that their remedy is to succomb to bullying and stop using the product: even while admitting that smokers subjected to denormalisation for smoking could absent themselves from necessary medical treatment, at risk to their lives (i.e. admitting that the denormalisation process could be more damaging than actually smoking in the short term). In its crusade against tobacco companies, it is not only denormalising smokers, it is also disenfranchising them, and not only smokers but also anybody who is employed or otherwise associated to the tobacco trade, howsoever marginally.

I am delighted that Frank Davis has concluded, three years on, that denormalisation hasn't worked (as above)!

Link to more of Rose's research (a forum in the Forces Tavern: (free) registration required)

Four degrees of separation

Obesity gains ground in the fight for funding in the United States. The Robert Wood Johnson Foundation is now spending over ten times as much on obesity as on anti-smoking.

We learn two things:

The rationale for designated smoking areas was based on the stated premise that secondhand smoke is medically dangerous to nearby people who might inhale the fumes.

There is no question that secondhand smoke can be unpleasant; few nonsmokers want to sit in a cloud of tobacco dust or have tobacco smell on their clothing or hair. But is it dangerous to your health? A study of 35,561 spouses of smokers followed for 38 years published in the British Medical Journal in 2003 showed that second-hand smoke is an irritant, but does not cause life-threatening disease. Actually, "secondhand eating" may be more dangerous.

With it so far. But it continues:

When people with whom we are closely associated gain weight, such as a spouse, sibling, neighbor or friend, we are also at an increased risk of gaining weight. For example, if your friend becomes obese, you have a 177 percent increased risk of becoming obese. If your friend's brother becomes obese, your risk is still increased. The increased risk goes out to four degrees of separation.

Okay. But what happens if they lose weight? And why is your friend putting on weight if you're not putting on weight?

As usual with such absurdly focussed studies, this leaves more questions than answers.

Secondary smoke has allegedly left one thousand a year dead in Scotland and seventy-nine thousand in Europe, without us knowing with any certainty who any of these people are. It is nice that Dennis Gottfried points out that smoke is actually only an irritant, even if only to convey the idea that obesity is a more urgent problem than smoking these days.

If this is any indication of the quality of 'obesity-related science', it looks even more akin to witchcraft and/or guesswork than the 'science' of secondary smoke.