TOBACCO thebmj.com • Read more articles about tobacco and smoking in The BMJ at bmj.com/specialties/smoking Why e-cigarettes are dividing the public health community The tobacco industry used to be seen as the enemy of public health, but the move into e-cigarettes 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 nicotine 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 cigarette (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 Tobacco Control. “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 tobacco harm reduction.” 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.