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Vaping as a Stick

I’m sure I don’t need to remind you, but vaping isn’t a stick to go around beating smokers with. It isn’t purely a cessation tool, though most alphabet organisations would love you to believe that.

Sure, most vapers view vaping as a way off tobacco and bully for them. Some view it as a cessation method; ‘cos they wanted to stop smoking and nothing else worked for them. Again, bully for them. Vaping is, by and large, a flexible and thoroughly enjoyable pastime.

Thing is, most in public health, and tobacco control in particular, will never see vaping as anything but a cessation tool, or a threat to their funding. They would love to have vapers work with them to “end the tobacco epidemic“, and while yes, beating public health around the head with a stack of evidence to get them to back off has had a remarkable effect; after all the UK is the most forward-looking on ecigs, it is far from being perfect. Mostly, public health and tobacco control should just fuck off, and leave us alone.

But they won’t. Natch. Instead, they come up with stuff like this, or this to justify their continued interference. Y’see, many in tobacco control want cigarettes gone, only, in the US that isn’t possible because of the Master Settlement Agreement actually prevents them from banning cigarettes, so they ban their use in all kinds of places, impose taxes, and other tripe to “eliminate the tobacco epidemic”. You’ll see the same pattern, at various levels, worldwide. Tax, ban, raise age limits, getting rid of the “glitzy packaging” and so forth.

Our projections show that a strategy of replacing cigarette smoking with vaping would yield substantial life year gains, even under pessimistic assumptions regarding cessation, initiation and relative harm.

Oh boy.

Y’see, by taking a known baseline of data – in this case the prevalence rates from 2016 – they can model possible outcomes based on a variety of scenario inputs. Naturally, there’s a few flaws inherent in such a study. The biggest of which is having to make assumptions based on nothing other than historical data (which is hilariously skewed, inconsistent, misinterpreted and often incomplete) and finger-in-the-air guesswork.

The analysis begins with a Status Quo Scenario for smoking rates and health outcomes. E-cigarette Substitution models are then developed in which cigarette use is replaced by vaping. Projected mortality and life years lost (LYL) under the Status Quo and E-cigarette Substitution models are compared to determine the public health impact.

Having some reliable baseline data would, of course, help solidify the substitution models, but of course in the US, reliable data is a misnomer, especially if the data needed has to span decades. It is only in the last five or six years that the US has started generating some reasonable data, mostly through the Monitoring The Future survey. Other surveys, like the National Youth Tobacco Survey, and CDC are usually used as political tools. Surveys, especially area specific ones like a smoking survey, are littered with selection bias, which is why broader surveys are used; like the ONS Lifestyle Survey in the UK, however it doesn’t give the fine detail that other specific surveys provide.

There’s another flaw, and it’s quite a significant one.

The Status Quo Scenario focuses on cigarette use and is initialised in 2016 with the population classified as never, current and former cigarette smokers. Due to data limitations and to simplify the analysis, the Status Quo Scenario only considers cigarettes, and does not include smokeless tobacco, e-cigarettes or cigars.

There’s a huge chunk of data missing then, so the picture isn’t complete.

To distinguish between successful cessation and short-term cessation followed by relapse, cessation is measured as having quit smoking for at least 2 years.

Shifting goal-posts anyone? The usual cut-off for ‘successful cessation’ is 52 weeks, in this paper, you’re only a “successful quitter” if you’ve made it to the two-year mark. Other studies and data uses one threshold, while this uses a completely different one. Another flaw.

Under the Status Quo, the number of smoking-attributable deaths for current smokers is calculated by age, sex and year as the product of their excess mortality risks (ie, current smoker mortality rate minus never smoker mortality rate) multiplied by the number of smokers.

Given that, in the US, smoking is attributed to a dizzying array of deaths, that figure is likely to be grossly over-estimated.

Starting with the same proportions of smokers, former smokers and never smokers as in the Status Quo Scenario, the two E-cigarette Substitution Scenarios were constructed to show the impact of substituting e-cigarette use for cigarette smoking. The Optimistic Scenario is based primarily on current use patterns in e-cigarettes and published evaluations of harm reduction, while the Pessimistic Scenario is intended to reflect the ‘worst case’ of suggested harms (eg, with e-cigarettes more harmful than the science indicates), and the switching strategy substantially increasing vaping beyond those who would have smoked in the Status Quo Scenario.

The “Optimistic Scenario” assumes that, by the end of the predicted time-frame, smoking prevalence is down to 5% (by 2100), and in the “Pessimistic Scenario” the prevalence is ‘only’ down to 10%. It is entirely possible, that by 2100 the smoking prevalence has declined that far, but it is also entirely possible that the rate will remain stagnant. No-one knows with any degree of certainty, and that is (yet another) problem. Even harsh taxation and other policy measures, as demonstrated by Australia, hasn’t had a substantial impact on smoking prevalence.

Those who replace cigarettes with e-cigarette use before age 40 years are treated as never smokers using e-cigarettes, since their risks as former smokers will be close to that of never smokers.

Wordplay. From a physiological point of view, the body has recovered significantly from the effects of smoking (it is a wonderful self-healing machine after all), but this is the only paper I’ve read that treats former smokers as never smokers if they’ve stopped smoking before a certain age.

Those who replace cigarette with e-cigarette use after age 40 years are treated as former smokers using e-cigarettes.

More wordplay. There is some evidence from Ricardo Polosa that e-cigarettes do have potential harm reversal effects, so you could (theoretically) assume that ‘late switchers’ have an accelerated risk reduction rate.

Thing is, there’s another (rather large) flaw in this paper, which isn’t highlighted as a limitation by the authors, rather it is highlighted as a feature of it.

Unlike previous models of e-cigarette use, our model was not developed to predict future e-cigarette and cigarette use based on past trends. Rather the aim was to examine a hypothetical endgame strategy of reducing cigarette use through switching to e-cigarettes. As with any hypothetical modelling exercise, a number of limitations are worth noting.

So plug in some random numbers and see what comes out the other end. It is fair to assume that the authors random numbers have some basis in reality, but are likely to be grossly over, or under, exaggerated.

The projections do not incorporate tobacco control policy changes and the effect of increases in e-cigarette use that have occurred after 2012.

So, despite trying to predict rates of prevalence with e-cigarettes as a factor, they are ignoring any and all cofounders resulting from policy implementations since 2012. Pie in the sky much?

The residual prevalence of cigarette smokers will depend on the potency of policies directed at cigarette use. Traditional cigarette-oriented policies, including significant cigarette tax increases, large and graphic pictorial warnings on cigarette packages, and retail point-of-sale restrictions on advertising displays, have each been projected to reduce smoking prevalence by at least 10% in relative terms.

Ah yes, projections of tobacco control policies. Well, look at Australia, or even the UK and see how much of a prevalence decrease they’ve had since the introduction of these exact policies. Both saw a slow decline since the introduction of these policies, with an uptick in the rate of decline after e-cigs appeared on the market.

A nicotine reduction policy may substantially reduce cigarette use if properly enforced, especially when accompanied by a more permissive approach to e-cigarettes.

Well well. This is telling isn’t it? This is, of course, in reference to the FDA and it’s Very Low Intelligence idea for cigarettes. You see where this is headed yet?

Substitution from cigarettes to e-cigarettes will also depend on the policies directed at e-cigarette use. Information dissemination policies that provide the best available information on the relative risks of e-cigarettes are likely to encourage switching to e-cigarette use. In addition, just as innovations have improved both the appeal and delivery of nicotine in a satisfying manner, innovations are likely to improve the substitutability of e-cigarettes for cigarettes, unless there are major regulatory hurdles for introducing new products.

Well, we already know what the current regulatory landscape looks like, albeit delayed, don’t we? There doesn’t seem to much change in that area, so we can (quite safely) assume that the substitution rates will decrease significantly.

An endgame scenario for cigarettes might well be within reach, if new technologies for delivering nicotine with substantially less harm, but sufficient satisfaction, are harnessed with sufficient passion and political will to aggressively phase out tobacco cigarettes.

Where have I heard that before?

If this isn’t the greatest evidence presented that public health and tobacco control aren’t interested in e-cigs for what they are – a recreational product – then I really don’t know what is.

Granted, the benefits of folk switching to e-cigs can be significant, but here’s the thing; this trend had started long before public health and tobacco control stuck their collective noses into our business. First, by trying to ban it all (because that’s what authoritarian fuckwits do), then by using it as a “cessation only” tool. Not one of them will ever support it for what it is.

It’s past time folk realised this, especially given the comments from Dr Marita Hefler:

the rapid evolution of alternative nicotine products, such as e-cigarettes, meant outlawing combustible tobacco, including cigarettes, was now possible.

This of course comes hot on the heels of the biggest scream test devised against tobacco control and amid calls by a number of sock-puppet alphabet organisations for Phillip Morris to stop selling cigarettes “immediately”.

Like it or not folks, tobacco companies are going to be around for a while yet and on top of that, they have the retail chain and spending power to allow alternatives like Heat-not-Burn, e-cigarettes and Snus to continue to be provided as choices to those that want them.

Nothing that tobacco control, or public health have done have made any significant impact on the tobacco industry. The only people who lose out are the likes of us. The consumer, while the taxes that are applied to tobacco (and no doubt e-cigs at some point) fund their authoritarian snobbery.

Remember, we’re on the side of the angels and e-cigs continuing to demonstrate exactly what public health are trying to do, and it isn’t about our health.

(image credit Darkbird/shutterstock.com)

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