I recently wrote a blog for the website of the Wellcome Institute called Guerrilla Public Health. It was a brief overview of the history of harm reduction in the UK and centred on the fact that the early days of harm reduction were really driven from the bottom up, by drug users themselves concerned about their health and supported by other enlightened health professionals. It was the introduction of needle exchange schemes and a far more flexible approach to opiate substitute therapy that kept incidence of HIV among UK drug users down to some of the lowest levels in Europe. From small and isolated beginnings, the drug harm reduction movement now has global reach.
One of my favourite Woody Allen quotes come from his film Stardust Memories which goes, “intellectuals are like the Mafia. They only kill their own.” Fortunately, within the conflicted world of tobacco control and tobacco harm reduction, there are relatively few albeit influential sabre-rattlers. But this area of public and scientific discourse is relatively new, so plenty of time for the dogs of war to be let loose. I’m sure the hurricanes of hate blow through the climate change community and there is this salutary tale about Amy Cuddy, a social psychologist. She built a career on research around power posing, the idea that briefly adopting assertive, open poses can improve one’s performance in various social settings (in part because doing so cues certain hormonal changes).
There is a long-standing and recognised procedure for the publication of academic papers. They go through a peer-review process, suggestions may or may not be made by anonymous reviewers back to the authors. Ultimately the paper may or may not be finally accepted. If it is published, then there may be a letter or letters to the editor criticising the paper, sometimes on grounds of methodology or conclusions drawn from findings. The original authors are given a chance to respond and life goes on. This is the normal cut and thrust of academic publishing. In that world, it is a question of publish or die and if you do put your head above the parapet, be prepared to be shot at.
There are some cracking reads to highlight this week. This one by Adam Creighton in The Australian reproduced in full here because of bloody paywalls. Disruptive technology or what! I would take issue on a couple of points. First, people don’t inject methadone in drug consumption rooms and recent revelations about Big Tobacco antics don’t get current executives off the hook of past misdemeanours. That said…..
Ban on nicotine will do us more harm than good
You don’t have to be a medical insider to understand that smoking a substance that causes cancer is a lot more damaging than smoking one that doesn’t.
The wires this week were not so much humming as soaring in full operatic splendour over the vexed subject of whether addiction is a brain disease (hereafter BDMA or Brain Disease Model of Addiction). It was sparked by a very interesting development in the addictions field, akin to the split among academics, clinicians and public health officials over safer nicotine products.
A fissure has opened between those who subscribe to the BDMA and those who believe that the phenomenon of addiction is far more complex than such a reductionist conclusion allows. While the American psychologist Stanton Peele has been challenging the BDMA for years, he has often been a lone figure in an addictions landscape where the BDMA has become the orthodoxy, promoted vigorously by the multi-million-dollar US addictions industry and by such august bodies as the US National Institute on Drug Abuse, a federal agency which funds more addiction research than any other institution on the planet.
An economic forecasting company has estimated that if smoking in the UK declines at the current rate, nobody will be smoking by around 2050. Frontier Economics predicts that:
1. Our central forecast is for the Government to meet its smoke-free target – to reduce smoking prevalence to 5% or below of England’s adult population – around 2040. This forecast is based on a continuation of current above-inflation excise increases and known regulatory interventions.
2. If smoking then continued to decline at the same rate after 2040, it would reach 0% in around 2051.
3. Smoking is in long-run decline, but since 2012 it has declined at more than twice the rate seen between 1993 and 2011. Smokers switching to e-cigarettes appear to have made a material contribution to that recent trend.
My friend Ethan Nadelmann once told of a conversation he had with an officer from the US Drug Enforcement Administration. Ethan asked him if there was anything they could agree upon, any common ground across which a bridge could be built. The officer replied that the wall between their views was just too high for him to want to climb over and engage in meaningful dialogue.
On the strength of the latest example hot from the desk of the WHO, I fear that is where we are with this agency too. It almost seems pointless to continue berating the WHO over its intransigent opposition to safer nicotine products (SNP). At one level it is a bit like continually criticising the DEA for not supporting drug law reform. Except the DEA is a law enforcement agency; they have a remit to enforce the drug laws whatever they might be. They don’t have a mission to be concerned about the welfare of drug users – and they aren’t. But the WHO is supposed to be an agency with a ‘health for all’ remit, so the deliberate undermining of efforts to increase the availability of SNP is something that should be highlighted at every turn.
Insightful read of the week award goes to a review of a new book on the AIDS pandemic in which the authors reveal how the leadership of the WHO failed miserably to save thousands of lives until redeemed by an administrator, Dr Jonathan Mann who did everything right from inaugurating World AIDS day to involving NGOs and fighting stigma and discrimination. Yet he felt he had to resign from WHO, frustrated that his boss was just putting every obstacle in his path. Mann tragically died in an air crash in 1998.
In May, the Icelandic pro-vaping coalition Veipum Lifum (VL) held a conference in Reykjavik. On their website, they included a link to the WHO FCTC as well as links to the Icelandic Parliament and an article in Icelandic media both of which also carried the WHO logo. On 18th August VL received a letter from the legal unit of the WHO Regional Office for Europe threatening legal action stating that they had not given permission for the logo to be used especially as placing it on the VL website suggested that the WHO endorsed the use of e-cigarettes. The WHO demanded that the logo be removed not only from the VL website, but also from the other locations over which of course, VL had no control. The letter also said that examples of ‘misuse’ of the logo were attached which they were not.
Cigarette smoking continues its rapid decline in Japan while the upward trajectory of smokers seeking alternative nicotine products shows no signs of slowing down. According to PMI a small percentage (calculated variously at between 5—15%) of their IQOS customers are dual users, but the rest have fully converted. The access to the market for companies like PMI afforded by the Japanese government plays a big part in this; advertising is seemingly allowed in any ways the imagination can conceive and is just as ubiquitous as the most aggressive cigarette advertising. Tobacco regulators around the world may choke on the vapour here, but the experience in Japan strongly suggests that putting obstacles in the way of e-cigarette and HNB marketing simply prolongs your cigarette problem.
The heat and dust continues to swirl around the Foundation for a Smoke Free World https://www.smoke-freeworld.org/leadership.
Whether the negativity continues will very much depend on what it actually does, although suspicion will always dog its tracks no doubt. The WHO have weighed in with a statement urging all governments and public health bodies to steer clear and refuse any collaboration: https://www.cnbc.com/2017/09/28/who-tells-governments-to-reject-philip-morris-funded-smoking-foundation.html