GFN 2016: Evidence, Accountability and Transparency – Part 2

Moving on from my previous post in this multi-part series of my coverage of the 3rd Global Forum on Nicotine, the conference proper started with the Michael Russell Oration, presented by Marewa Glover.

Russell Oration

Entitled “Pioneering with Compassion” (Marewa’s slides are available from here) Marewa highlighted several key points, the biggest of which:

While there is low overall smoking prevalence, there is large disparity in sub-population groups

A point made early in the presentation with 42% of Mãori women and 34% of men - which when averaged give a total of 38% compared to the overall population of New Zealand total of 15%. Consider how many “sub-cultures” there are in any number of countries, then consider how many of that sub-culture smoke then look at the “overall” prevalence figures. It’s a terrifying disparity, and it is, unfortunately made worse mostly through the actions of tobacco control.

Once again, the work of Michael Russell feature prominently. Years ahead of his time, Russell is known for his pragmatic approach to nicotine:

More rapid progress in our efforts to promote cessation is hampered by smokers’ addiction to nicotine. One way to reduce the difficulties in giving up smoking is to provide nicotine from an alternative and less harmful source.

Unfortunately, tobacco control hasn’t been so forthcoming in providing the widest source of less harmful alternatives. They’ve tended to stick to the usual suspects - the gums, the lozenges and the patches, something Marewa was clear to highlight - along with the variety of terrible mistakes made, such as naming, blaming, shaming and demonising smokers in an effort to get them to stop smoking.

“To incite hatred in the general public against smokers”

This is something that, I think everyone can agree on. Tobacco control have gotten it very very wrong, for a very long time. Even going as far as suggesting “Electric Aversion Therapy” - yes, you read that right. Electro-shock therapy for smokers. Published in the BMJ in 1970.

Slide on electric aversion therapy

Marewa then showed a few of tobacco control’s “highlight ads” which are as distasteful as you would expect from a group that actively goes out of its way to shame and demonise smokers. The worst of all was this one:

Shame them slide

Deliberately picking on one single aspect of a culture, and this was prevalent in the media at the time.

Marewa then described the difficulties in reaching the “poorer” element of each culture - as we know, the biggest decline in smoking prevalence is among those in higher socio-economic groups, yet the smoking prevalence is still incredibly high in the lower groups. The mission of Marewa and her team?

Slide on Marewa’s mission

Speaking on innovation, why not bring in other disciplines - ones outside of the usual spheres of influence, bioengineering for example. Other techniques and technologies are already available, why not repurpose them for something else? A needle free subcutaneous delivery system for nicotine for instance, collaborative family starter kits, even a vaping station (shown as the tea lady, prompting a chuckle from the audience).

Marewa then expanded on how stopping smoking can be viewed as a game of snakes and ladders - “we need to add more ladders” - with every relapse being a downward slide on the back of a snake. Vaping, as Marewa suggests, is another ladder.

What we’re dealing with is a human problem. Teach the next generation of public health and tobacco control to avoid past mistakes.

~ Assoc. Prof. Marewa Glover, GFN2016

Following on from Marewa came Amelia Howard discussing vaping as “Innovation by, and for smokers”. Interestingly, Amelia described vaping as being a globally dispersed highly local social movement. From her standpoint, coming from being confused as to whether she had done something wrong when she first tried vaping, to eventually stopping smoking via vaping by researching the product. Thing is, her research hasn’t stopped. Currently writing a dissertation about the role of the internet in facilitating innovation and practice, and the political controversy over vaping technologies.

She discovered, as I have, that the first “e-cigarette” wasn’t really the one developed by Hon Lik, there are US patents ranging from 1936, but unlike Hon Lik, the early devices didn’t capture the imagination of the consumer. It was this consumer encounter with the device from Hon Lik that truly sparked what we know as the vaping community & industry today. As with most entering the community for the first time, Amelia noticed that there is a specific “language” - created specifically to capture the various terms and practices associated with e-cigarettes and vaping - the “words of practice”.

Sadly, I didn’t make as many notes on Amelia’s talk as I should have done - that’s mostly because she had my complete and undivided attention throughout so I forgot to take notes. It’s a simple as that.

Unfortunately, due to ill-health Donna Darvill wasn’t able to attend the conference itself (wishing you a speedy recovery Donna!), instead Dave Dorn spoke in her place. Completely unrehearsed, off the cuff, and deserving of a standing ovation Dave spoke about the pleasure principle, the enjoyment - all the things we instinctively know. Again, no notes on this as Dave is a superb orator, so do make sure to watch the video.

The final session of Day One was all about science - making sense of it to be precise. Dr Konstantinos Farsalinos (slides), Professor Linda Bauld (slides), Ann McNeill (slides) and Karl Lund (slides) discussed the various papers and the media frenzy. Dr Farsalinos in particular was very critical in how the media portrays the science on e-cigarettes - calling it a “media frenzy” which is leading to a “science frenzy” - unfortunately it is this “frenzy” that is making this debate worse.

The formaldehyde stories (thanks to the New England Journal of Medicine) spread far and wide, culminating in Dr Farsalinos having to recreate the study himself - you know, this is what science is about reproducibility - only to discover that (as we know) when a device is pushed beyond its limits, we get the dry puff. Dr Farsalinos followed this with reference to acceptable upper limits for “clean indoor air” of 2000µg/day (WHO defined limit) for formaldehyde - considering that it is present in a lot of places, that’s a high “limit” - as opposed to 678µg emitted from e-cigarettes.

Dr Farsalinos covered researchers misinterpreting results, or even going as far as using the wrong method of deviation:

More science was discussed, this time in relation to blood pressure (BP) and aortic stiffness - once again Dr Farsalinos highlighted critical errors in the measurements taken, highlighting that to measure aortic stiffness, subjects have to “refrain for at least 3 hours before measurements” (smoking/eating - particularly drinking caffeinated drinks) - instead the paper measured aortic stiffness after 30 minutes of e-cigarette use. Not the three hours recommended.

Despite high tobacco use in the form of Snus, Sweden and other countries where Snus is available have the lowest death rates attributable to smoking - a proof of concept that harm reduction works.

Farsalinos Slide

Long term evidence is definitely needed, but we should avoid the “parachute phenomenon”

Following Dr Farsalinos was Linda Bauld, with one of the strongest opening statements:

The research community should be doing better

She’s right of course, the research community is both deeply divided on this topic and has some deep ideological issues to contend with. We’ve seen the question posed in the US - the long-term use of non-combustible nicotine (as in e-cigarettes) is an acceptable, if not ideal, alternative to continued cigarette smoking - we’ve seen the original stats on Twitter - let’s see how the UK stacks up:

Long term use of non-combustible nicotine is acceptable stats

Quite remarkable isn’t it? Thanks to this difference (and no doubt there’s significant differences in the rest of the world), this of course leads back to the media/science frenzy that Dr Farsalinos covered, but it really boils down to some fundamental flaws:

  • Recent studies drawing conclusions not supported by the findings
  • Wrong questions being asked
  • Response categories are combined in the analysis
  • Important distinctions not fully understood by the researchers

Clear case in point is the recent University of Stirling study on point of sale advertising where responses like “I have never used them”, “I have tried them once or twice”, “I use them sometimes (more than once a month)”, “I use them often (more than once a week)” were classified as “ever tried” or “never tried” leading to questions on whether or not the participant remembers seeing e-cigs displayed for sale in the past 30 days. We all know the headlines associated with that study.

Linda then succinctly put the Glantz meta analysis in its place which prompted a few chuckles from the audience (and a quiet cheer from yours truly). In summary Linda touched on the need for better questions and a far better understanding of the terminology - it’s understandable that bias and agendas can’t feasibly be eliminated, but better and consistent questions are needed.

Ann McNeill spoke on the population impact, referring to the latest ASH data via YouGov dual use is to be expected in the early stages as it is, more often than not, a period of experimentation. McNeill also pointed out that dual use is not restricted to smoking/vaping but also to other nicotine products such as NRT. There have been a number of reports published on harm reduction, and smoking cessation - 2007 Royal College of Physicians, 2008 ASH Beyond Smoking Kills, 2013 NICE Harm Reduction Guidance (due to be updated soon), 2014 Public Health England (2 reviews), 2015 ASH Smoking Still Kills & PHE the Evidence Update and finally 2016 the latest RCP report.

Ann was highly disparaging of the negative coverage in the BMJ and Lancet that the 2015 PHE report received, which can (and has) reinforced public perceptions of harms, perceptions which are then later used to influence support for policy measures:

McNeill, Nicotine perceptions

McNeill, Relative harms

McNeill, Policy Support

Worrying trends aren’t they?

The final speaker for Day One - Karl Lund followed Ann McNeill’s example with a population impact of snus. Cracking jokes immediately - don’t visit Scandinavia, it’s cold, wet, expensive - sparked a relaxed atmosphere. Karl was an enthusiastic speaker and I thoroughly enjoyed his talk. Starting out with registered sales of tobacco, prior to WW2 snus and chewing tobacco held the greater market share, which has only grown and now corners 40% of the market.

Karl succinctly demonstrated the ridiculous smoking bans with some entertaining slides - coupled with some commentary on “possible solutions” to the outdoor smoking “problem” - the smoking mask and glove, or the smoking hole:

The Smokers ‘Hole’

The Smokers ‘Hole’

As a result of the smoking bans, snus began a substantial rise, with health gains from its use far out-weighing the health loss in the fraction of never-smokers taking up snus. Sadly, the regulatory landscape in Norway is bleak for snus:

Lund, Snus regulations

With snus on the receiving end of regulations similar to that of tobacco cigarettes it’s a wonder that the never-smokers among ever-users of snus is at 37%, but the number of former snus users that are currently smokers has drastically fallen since 2005. One concern highlighted by Karl is the potential for a tipping point whereby snus use among never smokers (thanks to a continuing decline in smoking prevalence) may lead to an increase in harm. However, to produce a net population level harm, 20 individuals that would never smoke would need to start using snus to offset the health gains from each tobacco user that chooses snus over cigarettes. It is unlikely the ratio will ever come to that, and the availability of snus will continue to provide a positive net effect for public health.

Lund, In that case…

A thoroughly entertaining day at the Global Forum on Nicotine. I’ve still to cover day 2.