thebmj.com • Read more articles about tobacco and in The BMJ at bmj.com/specialties/smoking Why e-cigarettes are dividing the public health community The used to be seen as the enemy of public health, but the move into e- and harm reduction has seen some experts shift their views. Are they right or does industry have more cynical motives? Jonathan Gornall reports

ven the man from British American Tobacco (BAT) struggles to keep the sense of wonder out of his voice as he recounts the strange event that took place earlier this year in San EJose, California. The occasion was the 2015 annual meeting of the American Association for the Advancement of Science. Sharing the floor at the San Jose Convention Centre were Public health divided? Deborah Arnott, Simon Capewell, Karl Fagerström, Gerry Stimson two unlikely bedfellows: Deborah Arnott, chief executive of the UK charity Action on Smoking in public health find themselves arguing in licensed replacement therapy and is and Health, and Kevin Bridgman, chief medical the same direction as the industry then, with unlikely to kill anyone?” officer of BAT’s electronic (e-cigarette) respect, we think that’s time to pause,” said company, Nicoventures. Simon Capewell, professor of public health Pragmatists versus idealists “Imagine that happening 10 years ago,” says and policy at Liverpool university’s Institute of Several experts on both sides of the harm Will Hill, public relations manager for BAT. Psychology, Health and Society. reduction debate that I spoke to characterised “We’re now starting to share podiums with If the big tobacco companies were genuinely the divide as being between pragmatists and people like ASH at e-cigarette conferences.” concerned about the disease and the harm they idealists. The pragmatists are often practising It’s a proposition that fills caused, says Capewell, “they clinicians with patients with progressive lung some in the public health “We’re now starting to would cease production—end disease who still smoke, and they can see how community with dismay. share podiums with of discussion. They would go they might be helped by switching even partly The subject of the sympo- people like ASH at into e-cigarette production to e-cigarettes. The idealists are generally those sium was “E-cigarettes: kill- e-cigarette conferences” 100%.” working in public health who take a population ing me softly or our greatest —Will Hill, BAT Capewell and others argue view and suspect the industry’s motives. public health opportunity?” that e-cigarettes help to glam- In 2014 the tension boiled over into a and Arnott and Bridgman—a former GP who is orise and renormalise smoking. Worse, he says, pitched battle of words, fought in public in the now working for Nicoventures offshoot Nicova- they are being used by the industry “as a trojan run-up to the sixth conference of the parties to tions—were singing from the same hymn sheet. horse to get inside ministries of health. They the World Health Organization’s Framework Arnott’s talk highlighted her concern that are saying ‘This is all about harm minimisation, Convention on . “some groups” were calling for an outright ban we’re part of the solution, we’re no longer the The first salvo was fired in May 2014, when on e-cigarettes, despite a lack of evidence of problem.’” 56 “specialists in nicotine science and public harm, “especially in comparison to smoking.” Over at ASH, however, Arnott summarily health policy” wrote to Margaret Chan, director She wanted to focus on “counteracting moral- dismisses such fears. “There are people in the general of WHO, to complain that the “critical istic dogma and separating fact from fiction.”1 public health community who are obsessed by strategy” of harm reduction had been “over- Bridgman’s message was that “regulators e-cigarettes,” she says. “This idea that it renor- looked or even purposefully marginalised” in should resist the urge to apply highly restrictive malises smoking is absolute bullshit.” Fur- preparations for the conference. Harm reduc- measures that would have the perverse effect of thermore, she insists, “There is no evidence so tion, they insisted, was “part of the solution, prolonging cigarette smoking.”2 far that it is a gateway into smoking for young not part of the problem.”4 For some, such an apparent convergence of people.” There was a swift retaliation from the other views is a sign that the industry’s enthusiastic— For Arnott, the concept of harm reduction side of the debate, signed by 129 public oppos- and, critics maintain, cynical—embrace of the boils down to a simple proposition: “Do you ing experts organised by Stanton Glantz, controversial concept of “harm reduction” in want the tobacco industry to carry on making director of the WHO Collaborating Centre on tobacco control is paying dividends. cigarettes which are highly addictive and kill Tobacco Control and American Legacy Founda- “If the tobacco industry is busy arguing for when used as intended, or do you want them tion distinguished professor of tobacco control deregulation and a number of our colleagues to move to a product which is much nearer at the University of California. the bmj | 27 June 2015 15 TOBACCO

It was “fundamental,” they wrote, that WHO he was a member of the NICE programme devel- and other public health bodies did not “buy opment group producing guidance on tobacco into the tobacco industry’s well-documented harm reduction. Minutes of the group’s first meet- strategy of presenting itself as a partner.” By ing, in October 2011, record he declared he had moving into the market, the tobacco industry “received hospitality from British American staff was “only maintaining its predatory practices and has reciprocated.” and increasing profits.” In May 2012 he had “attended a Christmas The original authors rapidly returned fire, drinks reception at British American Tobacco” accusing their critics of “an attempt to influence and in February 2013 it was noted that he was policy through misrepresentation of evidence.” “the director of a company, Knowledge-Action- The basic proposition of harm reduction, they Change, which has requested and received stressed, was not that the alternative nicotine development funding from [the BAT offshoot] products are harmless but that they reduce Nicoventures for a project to support smoking the risk by at least 95% more compared with cessation in a closed setting.”9 cigarettes and “provide a viable alternative to The NICE guidelines on which Stimson worked smokers who cannot or do not wish to quit.” were published in June 2013 and superseded an earlier document, published in 2008. The Industry embrace titles of the two documents tell their own story That BAT was following this spat with more than about the change of emphasis in the approach to casual interest became apparent when it quickly smoking: document PH10, “Smoking cessation a lobbying letter sent by Nicoventures to mem- incorporated a quote from the letter into its pro- services,” had been replaced by PH45, “Tobacco: bers of the Australian parliament in July 2014, motional material extolling the virtues of harm harm-reduction approaches to smoking.” offering them a briefing from Fagerström, who reduction. Stimson did not respond to requests for an is described as “a leading international smoking In a report, Harm Reduction: the Opportunity, interview. But in an earlier email he said that cessation/nicotine dependence expert.” BAT said an “increasing number of people in the “much of the work we need to do to reduce harm Fagerström told The BMJ that he had now scientific and public health community” were from legal psycho-active substances means that stopped doing consultancy work for Nicoven- “now advocating harm reduction as the way we will have to work with people who are produc- tures. He had supported the development of Voke forward for helping the 1.3 billion people world- ing and selling them.” because it was regulated, but the company was wide who continue to smoke despite the known E-cigarettes and other nicotine delivery sys- now working on other products that would not health risks.” tems had “huge potential . . . to help shift peo- be licensed as medicines. The only stumbling blocks to such progress, ple away from smoking,” he added. But “the Nevertheless, he considered e-cigarettes could according to BAT, were that few governments quandary for many public health experts . . . is have a role in reducing the harm caused by smok- currently supported harm that the solution to smoking ing and accused some in public health of losing reduction and that there “For some, it’s more about might well lie with the much sight of the true objective. were “some public health getting rid of the tobacco reviled tobacco industry.” “When I started to become interested in experts and organisations industry rather than Others clearly think so [tobacco harm] in the mid-70s, we wanted to with concerns that not helping the poor smokers too. One is Karl Fagerström, get rid of the diseases that followed tobacco,” he enough is known yet about or to-be smokers” a Swedish clinical psycholo- said. “But nowadays, there is a target conflict. For the health risks of e-ciga- gist who specialised in smok- some, it’s more about getting rid of the tobacco rettes and that they could undermine efforts ing cessation and nicotine dependence, was a industry rather than helping the poor smokers to denormalise tobacco use.” Such doubters founder of the Society for Research on Nicotine or to-be smokers.” were “also suspicious of the tobacco industry’s and Tobacco, and now runs his own consultancy. Another of the signatories to the pro-harm involvement in .” Fagerström wrote an article for Nicotine Sci- reduction letter sent to Chan was John Britton, To those suspicious of the concept of harm ence and Policy, the website run by Stimson’s an epidemiologist who heads the UK Centre for reduction, this was breathtaking. The industry company KAC.10 He has also accepted money Tobacco and Alcohol Studies, a network of 13 that had been killing so many people for so long from BAT in the form of its flagship harm- universities providing international research and was now planning to profit by offering a solu- reduction proxy, Nicoventures. policy development. tion to the very problem it had created—if only In March 2014 Fagerström was the coauthor “I’m no apologist for or friend of the tobacco all those obstructive scientists and governments of a paper published in Addictive Behaviours industry,” Britton told The BMJ. “But the fact is would just get on board. arguing that “the significant positive impact on people smoke tobacco because they are addicted One of those who had was Gerry Stimson, for- public health that could be gained from encour- to nicotine, and tobacco companies are in the mer director of the department of social science aging people to switch from cigarettes to licensed business of selling them nicotine. So if an alterna- and medicine at Imperial College London and medicinal nicotine products cannot be ignored.” tive means of delivering nicotine to them comes one of the organisers of the first letter to WHO The paper was funded by Nicoventures, and along it’s inconceivable that tobacco companies and the subsequent response to its critics. The Fagerström’s coauthor was Bridgman, then the will not get involved and seek to exploit it, and letter was published on the website Nicotine medical director of the company, which is now that’s a risk that has to be managed.” Science and Policy, a forum run by Stimson’s poised to market Voke, the first licensed medici- He was, he said, concerned at the way the company Knowledge-Action-Change.” nal nicotine product from a tobacco company.11 debate about harm reduction had evolved. Stimson has made no secret of his relations It isn’t the only time Fagerström has worked “Now it’s ‘The tobacco industry is getting with the tobacco industry. From 2011 to 2013, with the company. The BMJ has seen a copy of into this, the tobacco industry is evil, therefore

16 27 June 2015 | the bmj TOBACCO

“There are people in the public health community who are obsessed by e-cigarettes”

One of the problems, says Capewell, is that “the amount of time and effort that different public health folk are spending on fighting among themselves could be better used fight- ing the tobacco companies.”

Image makeover And, as the debate rages on, the tobacco industry is quietly exploiting the schism in public health to gain the moral high ground. BAT is already in the business of meeting with health regulators. An important way- point on the industry’s journey to self reha- bilitation was passed in September last year,

LUCAS JACKSON/REUTERS/CORBIS LUCAS when BAT became the first tobacco company as a policy this is a bad idea, and anybody who and Tropical Medicine there is no doubt that to win marketing authority from the UK Medi- argues otherwise is either an idiot or a tobacco tobacco companies are entering the e-cigarette cines and Healthcare Products Regulatory industry poodle.’” market “solely so they can say they are part of Agency for a medical product, the nicotine Public health experts who have grown up the solution.” inhaler Voke. Though it looks like an ordinary thinking of the industry as the evil opposition McKee freely admits he is “an e-cigarettes cigarette, it involves no heat, combustion, or “find it very difficult when the tobacco industry, cynic.” He has also been an active supporter of smoke and, thanks to its medicinal licence, whether you trust it or believe it, starts to look as ASH and says he has been “greatly dismayed” by it will be sold in pharmacies. if it is coming up with a product that is actually a its support for e-cigarettes. But there was, said But regardless of their true value in the bat- solution to some people’s dependence on smok- McKee, still no evidence that e-cigarettes were tle against tobacco harm, are all such prod- ing tobacco.” effective in helping people to quit smoking, with ucts anything other than a mere sideshow, For some, accepting this meant “softening a recent studies indicating that smokers who used designed to make the tobacco industry look position that many have built careers on, and them might even be less likely to quit than those good as cigarettes continue to kill up to half that’s quite difficult.” who did not. of the people who use them?25 But there’s another take on the tobacco indus- Indeed, a recent meta-analysis of 11 BAT says “we want to reduce the public try’s rush into the e-cigarettes market, and it’s published studies that compared smoking health impact of our products.” But anyone one that concerns Britton. cessation rates among smokers who used e- who thinks it would ever do so by heeding The industry, he says, “has been taken by sur- cigarettes with those who did not, concluded public health’s invitation to stop making prise by e-cigarettes. It would rather they weren’t that smokers who used e-cigarettes were “about them is fooling themselves, says Hill, its pub- there, but now all the companies are buying 30% less likely to quit smoking than smokers lic relations manager. them. The biggest threat is that they are buying who do not use e-cigarettes.”15 “We have made meaningful steps in our them to have them fail.” More recently, a draft report by the US Pre- journey to tobacco harm reduction,” he ventive Services Task Force concluded that insists. Profit motive current evidence was “insufficient to recom- On the other hand, “BAT is a legal business In September 2013, Bristol based Imperial, mend electronic nicotine delivery systems for [and] the lion’s share of our revenue and prof- the world’s fourth largest tobacco company, tobacco cessation” and that doctors should its, certainly for the coming years, is going bought Dragonite International, a Chinese com- direct patients who smoked to “other cessa- to come from the traditional cigarette side of pany credited with inventing the e-cigarette. A tion interventions with established effective- our business. year later, Imperial’s subsidiary Fontem Ven- ness and safety.”16 “Simply to turn off that side of the business tures launched Puritane, the company’s first would not be acting in the best interests of e-cigarette market.13 Personal attacks our employees, our partners and suppliers or, But the true value to Imperial of the £48m McKee says the debate about harm reduction of course, our shareholders.” Dragonite purchase may lie in the multiple e- has been invaded and clouded by personal No mention, in that sentence, of the best cigarette patents it now owns. It is too early to attacks on social media launched by “vapers” interests of the six million killed each year know conclusively how Imperial intends to wield (as those who use e-cigarettes describe them- by cigarettes.25 this sword, but in March 2014 the company’s selves) and others. After he wrote an article Jonathan Gornall journalist, Suffolk, UK e-cigarettes division launched legal attacks for The BMJ in 2013,19 “sceptical and raising [email protected] against nine US makers of e-cigarettes, claim- a number of questions, I got attacked beyond Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant ing they were in breach of its newly acquired belief.” interests to declare. 14 patents. “It has been seriously unpleasant,” says Provenance and peer review: Commissioned; externally For Martin McKee, professor of European McKee. “But when you’re getting that sort of peer reviewed. public health at the London School of Hygiene treatment you realise you’re on to something.” Cite this as: BMJ 2015;350:h3317 the bmj | 27 June 2015 17