Switch and quit
Ullekh NP | 28 Nov, 2018
IN THE MOVIE Tourist, Johnny Depp, who plays Frank Tupelo, an American in Venice who lands in mysterious circumstances after meeting a fascinating woman (Angelina Jolie), puffs on a vaporised cigarette, also called electronic or non-combustible cigarette, that is said to be 95 per cent less harmful than its burning counterpart. The 2010 thriller perhaps had the first global embedded ad for an e-cig, which has since then attracted attention as well as a lot of concern over its use by teenagers who find it easy to conceal the habit. The product has also incurred the wrath of a section of policymakers and lobbyists who have zealously created an impression that its use has to be discouraged as vehemently as the use of cigarettes.
Recent exclusive data, however, prove that by denouncing such harm-reduction tobacco products, policymakers the world over are turning a blind eye to alternatives that can cut risks smokers of traditional cigarettes face. In the process, as new studies suggest, they also hamper the fight against addiction to cigarettes, far more dangerous than vapes. Research across the world also shows e-cigarettes help smokers quit the habit quickly, notwithstanding misperceptions among doctors, smokers and officials who focus largely on teenage addiction to nicotine through e-cigs and their use of flavoured products that enhance their risk of exposure to dangerous chemicals.
Derek Yach is an unlikely crusader for e-cigarettes. Once a public health leader at the World Health Organization (WHO) and one of the architects of its Framework Convention on Tobacco Control, now ratified by 180 countries, he has invited sharp attack from former colleagues, a section of the media and researchers ever since he was named to head, in September 2017, a venture named the Foundation for a Smoke-Free World, promoted by tobacco major Philip Morris International (PMI). He has also been banned from tobacco-control conferences, with some researchers accusing him of moving to the ‘dark side’.
Yach, a New York-based, South Africa- born doctor who had been executive director for non-communicable diseases at the WHO, had himself earlier warned public heath activists of tobacco companies using fronts and consultancies to lure them to their side.
In an interview with Open, Yach dismisses all such criticism as rubbish and says he chose the “harm-reduction road” based on evidence he saw. He also hastens to add that the Foundation will be an autonomous entity that can’t be influenced by the funder. “The [WHO] stated that harm reduction was unproven and could renormalise the role of tobacco companies just when WHO was stepping up demonising and isolating them,” says Yach. He emphasises that even all those who are associated with him have been threatened with isolation and barring from WHO events. He goes on: “Note these were discussions with very senior officials held before I went public and despite sharing legal documents highlighting the specific efforts we have taken to assure our full independence from our funder.”
Research in various parts of the world shows that e-cigarettes help smokers quit the habit quickly, notwithstanding misperceptions among doctors, smokers and officials
He rues, “The efforts [we are now taking] were themselves recommended years before by leaders in tobacco control in a major review. Authors included Mitch Zeller, current head of tobacco control at the US [Food and Drug Administration], and Joanna Cohen, a professor at Johns Hopkins and major Bloomberg grantee.”
Yach’s aim is to help smokers switch to safer alternatives and finally quit. Even as anti-tobacco activists scorn the efforts of tobacco companies to invest in efforts to reduce harm as a ‘stunt’, Yach’s view, which he argued in a November meeting in London, is that with 1.3 billion smokers around the world, “we need a greater focus on addressing their needs as they try to quit (and the needs of tobacco farmers as demand for tobacco declines globally).” In fact, PMI has invested $80 million a year for 12 years in the Foundation, which, Yach says, will shortly open an office in India—especially aimed at finding safer alternatives to Indian tobacco products such as beedi, gutka and so on to help users “switch and quit”.
‘Switch and quit’, a phrase Yach frequently uses, has become a mantra of sorts for him. He isn’t the lone rider on this front though. Tom Miller, the longest serving state attorney general in the US who sued tobacco companies 20 years ago and won, now says US federal agencies are sending out “false, misleading and deceptive” information as regards electronic cigarettes. In a November 15th article in The Washington Post, he wrote, ‘Twenty years ago this month, I joined 45 other state attorneys general to enter into the landmark settlement with the tobacco industry. Since then, the U.S. cigarette smoking rate fell from 24 percent of adults to 14 percent last year—the lowest ever. We have the opportunity to go much lower. But we’re also at risk of reversing these gains if we fail to give smokers safe alternatives to cigarettes.’
Miller was responding to a knee-jerk reaction to reduce access to e-cigarettes with the aim of prohibiting its use by teenagers—a genuine concern indeed. He wrote: ‘We should take this epidemic of casual e-cigarette use among children seriously, but we should not overreact. To overreact and limit access to harm-reducing tools means that adults die.’
Foundation for a Smoke-Free World will shortly set up an office in India to work on developing affordable alternatives to deadly products such as gutka and paan variants
The likes of Miller and Yach are betting big on harm reduction as a bypass to stopping use of tobacco products, because till date no global effort to fight traditional tobacco use has achieved good results. The Foundation argues research shows ‘that about 90% of all publicly funded research in the areas of smoking cessation science and harm reduction are funded by, and executed by institutions in the US and Europe. These regions represent about 10% of the world’s smokers.’ This is in the face of the reality that half the world’s smokers and tobacco users are spread across India and China, and nearly 40 per cent of cigarettes are made in China.
A recent report, published by Knowledge Action Change and funded by a grant from the Foundation for a Smoke- Free World, underlines the dictum of the late British psychiatrist Michael Russell, who advocated harm reduction and was associated with the tobacco industry: “People smoke for nicotine, but they die from the tar.” Though harm-reduction proponents face vehement opposition from official public health agencies, evidence seems to suggest that ‘switching’ to safer tobacco alternatives, or non- combustibles, assist addicted smokers to quit. Likely substitutes to gutka and other dangerous chewable options available in India could be snus and similar products. Snus, of Swedish make, has been shown to slash health risks and addiction in the Nordic country. Snus is typically available in pouches and contains nicotine. Though significantly less dangerous than tobacco, it sometimes causes white patches in the mouth, gum recession, etcetera. “We will have to pursue such options in India to replace dangerous chewable products that are widely used in the country,” says Yach. Sweden has lowest rates of tobacco-related cancer, thanks to a widespread switch to snus.
The Foundation, in its study, estimates 1.6-6.6 million premature smoking- related deaths in the US could be averted over 10 years if smokers switched to e- cigarettes. According to this report, this extrapolates to 10-40 million premature deaths in China that would be averted over 10 years if smokers switched to e-cigarettes.
“I am hoping science will win out and that regulators will see that, from a risk perspective, you will be able to bring down death, disease and suffering” – Derek Yach, president, Foundation for a Smoke-Free World
“I am hoping science will win out, and that regulators will see that from a risk perspective, you will be able to bring death, disease and suffering down by encouraging competition [among tobacco companies to go for safer alternatives],” notes Yach.
The Foundation-funded report argues that users of different forms of smokeless tobacco show massive differences in oral cancer-related deaths: approximate risk increases nine and seven times with gutka and paan tobacco, respectively, versus a 1 per cent increase with snus.
Studies show that smokeless tobacco is responsible for 368,127 deaths a year in India, of which 59 per cent are women. Switching to snus could reduce smokeless tobacco-related deaths, the study claims. Despite cries of castigation from opponents, combustible cigarette use has decreased over the past two years by 25 billion sticks in Japan and 20 billion in Korea, cutting smoking prevalence by 25 per cent and 10 per cent, respectively. Besides, heated tobacco products account for 70 per cent of the switching in these countries and they cut toxic exposures by at least 90 per cent, according to studies collated and analysed in the report.
Harm-reduction initiators insist that not all arguments can be reduced to a moral one, but have to be viewed from a pragmatic viewpoint—by discouraging safer alternatives, official agencies and regulators are asking smokers to continue their habit of smoking combustibles and die. Foundation-funded reports classify e-cigarettes, though there are variants, as having three basic elements: a battery, which heats up a coil or atomiser, turning the flavoured e-liquid or juice into a vapour, which is then inhaled.
Yach points out rightly that most media reports that run down the use of e-cigs—sometimes done at the behest of industries that stand to benefit from rising cases of cancer—are unsupported by evidence. Which is what forced Miller to state that US federal agencies are guilty of “false, misleading and deceptive” claims on electronic versions of tobacco.
When asked why PMI still makes combustibles, Yach says, “If PMI stopped today, Japan Tobacco and the Chinese would snatch its market share. That is why we are starting to push for industry- wide change and, to make progress, we must engage them.” According to reports, China Tobacco has recently launched a new heated tobacco device, called Mok, which is being pitched as more portable than PMI’s IQOS, British American Tobacco’s Glo and so on.
According to research commissioned by the Foundation, ‘The new and safer options these companies provide very much fit into the zeitgeist of new technology. They offer consumers who want to continue using nicotine unprecedented choice.’ And healthier options, too. In India, Yach says, the Foundation will have to work on alternatives and be watchful of their prices to make them accessible to the poor who consume gutka and smoke beedis. “Throughout the world, risks of exposure to cancer-producing chemicals have been brought down drastically by safer alternatives to traditional tobacco. But regulators have not yet completely woken up to the science of it,” he points out.
Meanwhile, Gautham Hareendranath, a 19-year-old Cambridge-based student in the UK, tells me that most of his peers who use heat-not-burn tobacco products like e-cigarettes are those doing it out of fear of being caught by parents or college authorities. Since e-cigarettes don’t leave a giveaway smell, they are an easier habit to hide than regular cigarettes. Which is why, he argues, the use of such products is on the rise among young adults.
But to overreact and regulate the sale of these less harmful products would be to encourage combustibles and add to the global health burden routinely caused by Big Tobacco. Yach and others favour fewer regulations on their use, allowing e-cigarettes to help people kick the habit.
“After all, cessation bids have hardly worked,” says Yach, an ace long-distance swimmer with many records to his credit.
Of course, he has swum from being a hardy anti-tobacco activist to being what he calls a pragmatist who wants to use science and accept help from Big Tobacco funds to meet his lofty goals of cessation in the long run. ‘Switch and quit’ is the key, he reaffirms like a chant.