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E-cigarettes and children: advocates walking on both sides of the street?

13 Nov, 15 | by Becky Freeman, Web Editor

Post written by Prof Simon Chapman AO

Follow Simon on Twitter: @simonchapman6

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In a 2014 open letter to the WHO’s director general Margaret Chan signed by 53 researchers, it was argued “Controls on [ecigarette] advertising to nonsmokers, and particularly to young people are certainly justified, but a total ban would have many negative effects, including protection of the cigarette market and implicit support for tobacco companies. It is possible to target advertising at existing smokers where the benefits are potentially huge and the risks minimal.”

Clive Bates who “had a hand” in organising the letter but curiously did not sign it, is a former director of England’s Action on Smoking and Health. In that role, Bates directed and wrote one of the most excoriating critiques ever published of the tobacco industry’s long standing (and still running) denials of its designs on children.

In the October 2000 Danger in the Playground, Bates documented many of the most telling examples of candid industry talk about the vital role of children to the future of tobacco industry profitability. This accompanying powerpoint presentation (also authored by Bates) rubs it in even harder. These revelations were all made in internal tobacco industry documents released through the US Master Settlement Agreement between US state governments the tobacco industry, millions of which are now freely available here.

The tobacco industry’s business model about the importance of youth smoking was never put more succinctly than in this 1984 document from an RJ Reynolds tobacco official: “If younger adults turn away from smoking, the industry will decline, just as a population which does not give birth will eventually dwindle.” (“younger adults” was industry code from the mid 1970s for children and young adults, to be used in all written communications)

In a 2000 press statement at the time of the launch of the publication, Bates said “When you look at what they say privately, and compare it to their public posturing, the whole idea that tobacco companies might be working against teenage smoking is revealed as sinister self-serving public relations.  The more they try to define smoking as only for adults, the more they are saying ‘hey kids, smoking’s for grown-ups’ with a sly nod and a cynical wink.”

Today, Bates runs his own consultancy business and is a leading advocate of ecigarettes. Of 220 tweets he posted between Oct 1 and Nov 1, 80% were about ecigarettes. On a recent blog he wrote that when it comes to ecigarettes “There is little evidence of marketing to children, only assertions that certain ads or brands are designed to appeal to children but with no empirical evidence, and apparently minimal understanding of modern advertising.”

On reading this, I was struck by how far Bates appears to have moved in the 15 years since he wrote Danger in the Playground and so tweeted a juxtaposition of the two quotes above, asking “which Clive Bates to believe?”

Bates replied challenging this apparent inconsistency, arguing that his 2000 statement referred to tobacco companies while his 2015 statement referred to ecigarette companies. He argued that currently, the vaping market is worth 100 times less than the cigarette market and that “nearly all vape customers come from the ranks of existing smokers”, which he said explains why adult smokers are the target market for ecigs.

The same analysis can of course be applied to the current contribution of young smokers to the total cigarette market. For example, an early Australian analysis showed that while in one year the value of the underage market to manufacturers was $AUD18.7million, if 50% of young smokers continued to smoke, they would contribute $AUD112 billion at current prices to the industry across their lifetime.

Bates knows perfectly that tobacco companies understand the importance of smoking uptake by children to their future, but seems to believe that such a thought has never crossed the minds of ecig manufacturers.

In an extraordinary statement, he wrote that “there are good reasons why the e-cigarette companies, even tobacco owned ones, would not target adolescents … demand, reputational, legal and regulatory risk etc … it would be bad business.”

flavour

E-cigarettes contain many child-friendly flavors. Flickr/keoni101

This language only needs to be contrasted with the many counterfactual examples he supplied in his own 2000 publication. Yes, there are many good reasons why designs on kids need to be publicly denied. As one 1973 tobacco document describing a supposed anti-youth smoking initiative put it “This is one of the proposals that we shall initiate to show that we as an industry are doing something about discouraging young people to smoke. This of course is a phony way of showing sincerity as we all well know.”

In much the same way as the tobacco industry has long done, many of those promoting vaping are today trying to walk on both sides of the street on youth vaping. They know the reputational risk of openly saying that they are unconcerned about youth uptake. Whenever data show negligible uptake by youth, this is rapidly megaphoned as self-evidently a good thing. But when data show significant use, they try to spin this as being an entirely positive development where it happens: all children who are now vaping would have been smoking instead, these clairvoyants assure us.

In the USA today data from the US National Youth Tobacco Survey show that while cigarette smoking continues to fall in US teenagers, e-cigarette use has been dramatically increasing since 2011 and is now way ahead of cigarette smoking: there are now some 50% more middle and high school kids vaping than are smoking, with an estimated 340,000 vaping on more than 20 days each month. Advertising like this, and 3 year old birthday party favourite flavours like these which Bates thinks should be allowed, are plainly intended to beguile teenagers.

A recent systematic review in the Lancet of nicotine and psychosis concluded that “Daily tobacco use is associated with increased risk of psychosis and an earlier age at onset of psychotic illness. The possibility of a causal link between tobacco use and psychosis merits further examination.” It set out important arguments about why the “self-medication” hypothesis about nicotine (promoted by the tobacco industry) deserves reassessment against one where nicotine might be causative in psychosis. Such serious considerations demand that trite dismissals of nicotine as being as benign as “like drinking coffee or something” be condemned.

Clive Bates and others who signed his letter might like to comment on how “it is possible to target [ecigarette] advertising at existing smokers”; how many of these allegedly “adult targeted” ads would never attract the interest of non-smoking teens; and where parents can buy one of the miraculous magic filters that let such advertising through to smokers but somehow render it invisible or uninteresting to young non-smokers.

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  • Professor Chapman’s blog is largely based on comparing what I said in a report for Action on Smoking and Health (ASH) in 2000 about the conduct of tobacco companies with what I and many others are saying now about e-cigarette advertising. The key weakness in Professor Chapman’s argument is that the statements he compares were about two different things in a completely changed context.

    My 2000 ASH report “PR in the Playground” was not just about tobacco companies: it was about about the useless and cynical youth anti-smoking initiatives run by tobacco companies. Tobacco companies running campaigns to persuade young people not to smoke were never going to be convincing or effective and that report shows why. They were mainly about protecting the reputation of tobacco companies – hence the ‘PR’ in the title. I haven’t changed my views about those programmes one bit, though I don’t know if they still exist.

    But e-cigarette companies do not have programmes like this to my knowledge and Professor Chapman doesn’t suggest they do. My recent statements were about e-cigarettes, not cigarettes – another important difference. So he is comparing statements I made 15 years ago with statements made recently about something completely different in a radically changed landscape: there were no e-cigarettes in 2000. It’s not that surprising the statements look different.

    I hope that Professor Chapman is fully aware of the potential dangers built into the positions he holds. It would be a major public health error to treat cigarettes and e-cigarettes the same way, given the very significant differences in risk – e-cigarettes are likely to be at least 95% lower risk than smoking, based on what we know of the toxic constituents of vapour. For example, an important effect of banning e-cigarette advertising could be to protect the incumbent cigarette trade from competition from a disruptive low-risk technology that helps people to quit smoking – thus increasing harm. In the UK, we have evolved a quite pragmatic approach to controls on e-cigarette advertising, which is similar to that used to control alcohol advertising. You don’t need a total ban to deal with the odd rogue advertisement (and it will always be possible to find these in any sector). The UK Committee on Advertising Practice reports that the e-cigarette code is working well and shaping the behaviour of advertisers in the way intended.

    We rightly ban tobacco advertising in the EU because smoking kills 700,000 EU citizens per year. But no such justification exists for banning e-cigarette advertising. The most likely effect of e-cigarettes is to reduce the smoking related death toll in future – a negative death toll – assuming they are allowed to compete.

    The problem of unintended consequences goes beyond banning e-cigarette advertising. Much of the hostility towards e-cigarettes in the field of tobacco control, if translated into policies, misinformation or taxes, could have the effect of protecting cigarette sales and supporting smoking. I hope Professor Chapman will reflect carefully on what harms might be caused if his ideas are taken seriously by policy-makers.

    I also made what I think is a reasonable point about the incentives of the companies involved: that e-cigarette sector has a very large market of adult smokers to pursue as their potential customer base (this also applies to the tobacco owned e-cigarette companies who are fighting over market share). Adult smokers is where the data shows that they overwhelmingly do find their customers. The e-cigarette sector is small in every country compared to the cigarette trade (about $6 billion globally compared to $800 billion for the tobacco trade) so there is plenty of room to grow by eating into the cigarette trade. These companies would create unnecessary risks for themselves if they targeted teenagers, and they have no need to.

    Even if not targeted, some teenagers will use these products. Most public health experts are familiar with the idea that some adolescents engage in risky behaviours and try adult things, and I hope that isn’t a revelation to anyone in the field of tobacco control. The data show that the teenagers who do use these products are almost all smokers already or have ‘risk factors’ that mean they are likely to become smokers. To the extent it is displacing smoking, e-cigarette use may be creating a health dividend. It’s too soon to say if that is actually happening, but the trends are largely consistent with that effect and Professor Chapman should expand his thinking to accommodate that possibility.

    As far as consistency is concerned, in 2000 while still Director of ASH I was open-minded about the concept of the tobacco market evolving to low-risk nicotine products and even envisaged the challenge that this would create for some factions in the public health establishment. See my paper ‘What is the future for the tobacco industry” from Tobacco Control journal in 2000 and especially the section “How can the tobacco market evolve”, in which I imagine the rise of products a bit like e-cigarettes…

    http://tobaccocontrol.bmj.com/content/9/2/237.full

    What I said in 2000 about the future of the nicotine and tobacco market is, I think, a fairer test of consistency of my approach to e-cigarettes than what I said at the time about something completely different.

    My article from 2000 is not perfectly correct about the rise of e-cigarettes, but as a bit of crystal-ball gazing it is not a bad account of what has come to pass. Neither is it inconsistent with what I’m saying now. I was warning even then that we would need to put health first if the market evolved in this way, which it duly has done: leaving the much of the tobacco control community confused about its mission.

    Regrettably, this blog contains unfounded innuendo about my purpose that readers should discount. I don’t wish to engage Professor Chapman in personal animus, but I would like to explain my own motivation. I believe the ‘harm reduction’ agenda is a legitimate public health strategy in drugs, sexual health, alcohol and other fields within public health – and there is every reason to apply it to smoking. I have been consistent about this since 1998. I put a lot of time into this issue because I believe it has the potential to avoid hundreds of millions of premature smoking-related deaths in the 21st Century by making the cigarette obsolete for many or most users. Furthermore, I think it is consistent and synergistic with legitimate evidence-based tobacco control policy – the more you press people to stop smoking with punitive or coercive measures, the more important it is to have somewhere for committed or addicted smokers to go. That’s an ethical argument that tobacco control advocates would do well to embrace if they wish to succeed in their mission.

  • NutmegJunkie

    Nicotine, when administered via a tobacco free technology like an electronic vaporiser, is a not a threat to public health. In case you didn’t know, caffeine has also been identified as a causative agent in psychosis[1]. Does that mean we should reclassify caffeine as a threat to public health like you are suggesting nicotine we do with nicotine?

    1. http://scholar.google.com.au/scholar?hl=en&q=caffeine+psychosis&btnG=&as_sdt=1%2C5&as_sdtp=

  • Mister Blog Dog

    QUOTE: “In the USA today data from the US National Youth Tobacco Survey show that while cigarette smoking continues to fall in US teenagers, e-cigarette use has been dramatically increasing since 2011 and is now way ahead of cigarette smoking” – Prof Simon Chapman

    The survey you cite is badly flawed because it classed a teenage user as someone who had taken as little as a single puff on an e-cigarette in the previous 30 days, with no attempt to establish regular usage or even if the e-cigarette contained nicotine.

    The latest CDC survey (published in Nov. 2015) involving 36,000 participants, found that e-cigarette use was largely confined to smokers and former smokers. In fact, the survey found that only 0.04% of never smokers went on to become regular e-cigarette users.

    Prof Chapman. If you are going to cite a survey to reinforce your criticisms of people who you disagree with, please first make some attempt verify the quality of the survey.

    Many thanks.

  • Simon_Chapman

    Clive Bates reiterates his central argument that the tobacco industry and the ecigarette industry and their products are “completely different”, and that therefore what he wrote in Danger PR in the Playground (http://www.ash.org.uk/files/documents/ASH_625.pdf) in 2000 about the tobacco industry is irrelevant to the
    ecigarette industry.

    So how completely different are these industries? Both sell products with the word “cigarette” front and centre. Both sell nicotine delivery systems engineered to rapidly maximise repeat purchasing. Both cigarettes and ecigarettes involve repeated hand-to-mouth activity and the semiotically rich smoking performance of exhaling smoke/vapour. Marketers in both industries understand completely that their future commercial health is dependent on maximising addiction, attracting already nicotine dependent people to their brands, and, critically for the future, attracting those who have never used nicotine before (mostly kids).

    Bates fails to engage with my argument about the tobacco industry’s public virtues/private vices duplicity and why the very same public relations strategy would not also suit the ecigarette industry’s commercial goals. Does he really imagine that in the USA where today there are 340,000 children vaping more than 20 days a month, that ecigarette industry investors are anything less than ecstatic?

    My blog post was about what I consider the folly of allowing the sort of open slather advertising for ecigarettes we see now in some nations. The 53 signatories of the letter to Margaret Chan agreed that “Controls on [ecigarette] advertising to nonsmokers, and particularly to young people are certainly justified” and that “It is possible to target advertising at existing smokers where the benefits are potentially huge and the risks minimal.”

    So when a vaping adult on the couch next to their 10 year old sees a TV ad for a gummy bear flavoured product, how does it target the adult, but go right over the child’s head? Please enlighten us Clive.

    He argues that “the odd rogue advertisement” for ecigarettes may get through industry advertising self-regulation systems, but that in England this system is working well. I suggest that Clive should read his own work far more carefully. On page 22 of Danger PR in the Playground he will find a section explaining why voluntary advertising codes have “failed” and that “voluntary agreements have served the industry well and the public badly”.

    Blithe dismissals of teenage vaping as some kids just “trying adult things” ignore the unprecedented success that several nations have had in the last decade in dissuading hundreds of thousands of kids from ever just trying cigarettes (or any form of nicotine).

    Bates says that ecigarettes help “people to quit smoking.” There are certainly many people who attribute their smoking cessation to ecigarettes, but the best population cohort study we have (from England) shows (http://onlinelibrary.wiley.com/doi/10.1111/add.12917/epdf) that at 12 months “Daily use of e-cigarettes while smoking appears to be associated with subsequent increases in rates of attempting to stop smoking and reducing smoking, but NOT with smoking cessation.” (my emphasis). To the great delight of the tobacco companies, the most common scenario for even daily vapers is dual use. The Brose et al paper from England (http://onlinelibrary.wiley.com/doi/10.1111/add.12917/epdf) reported that at 12 months, 13.9% of daily e-cigarette users reduced cigarette smoking substantially. But let’s turn the last figure around. Even among those smokers who vaped daily, 86.1% did not even cut back smoking substantially. That’s how good e-cigarettes are at just reducing smoking.

    I have never made any public statement supporting the prohibition of either cigarettes or ecigarettes. Clive and I have common ground in sharing the belief that committed or addicted smokers should be able to access products that satisfy their craving and that ecigs are almost
    certainly going to be far less hazardous than smoked tobacco.

    But it does not follow from this that such access should be a free-for-all, with unrestricted advertising and unregulated products. Charlotta Pisinger’s updated review of the evidence presented at the recent ecigarette summit (not yet online) should give much pause to those thinking that ecigs are as “harmless as coffee” and should be regulated to an equivalent degree.

    There are only two nations in the world – the USA and New Zealand – where direct-to-consumer advertising of prescription drugs is allowed. These drugs are designed to save lives, restore health, ease severe pain etc. Almost every household at any time has people using prescribed drugs. Sometimes these are for life, sometimes for limited periods. These limitations on accessing and publicising these products do not see mass consumer wailing about
    heinous restrictions. There are not queues of governments lining up to adopt the US approach to prescribed drug advertising.

    We made every mistake possible in how cigarettes were sold and marketed. We need not repeat the same mistakes with ecigarettes.

  • Professor Chapman: Sweden has 9/10% daily smoking respectively and 50% of total tobacco being smokeless and accounting for exactly 0% of tobacco related disease. Banned marketing and dissuasion campaigns by Public Health and full tax. What would you believe those numbers would have looked like if there was responsible marketing to smoking adults, active (total) switching promotion by Public Health and preferential tax treatment? I would like to see a Public Health/Sociology modeling of “expected” results from such a multimodal intervention. What COULD be achieved is a perspective that is sorely lacking in your analysis and advocacy.

  • Simon_Chapman

    Andrew, an alternative scenario is that BT is very keen to get a nicotine delivery product between the lips of smokers during the hours/places when smokers cannot smoke. This way they get to profit from smoking & vaping, not one or the other. What would stop BAT also moving into tank systems as well as ciglaikes? It’s not that they are short of the money required … We know that most ecig users keep smoking.

  • Andrew Thompson

    1) Dual use is a good thing. It reduces the number of cigs. smoked, (unless you presume that smokers would not otherwise be willing to avoid enclosed spaces simply because they cannot smoke – I often did). Further, if 50% of smokers begin dual use of using e-cigs/cigs and 20% eventually move to sole e-cig use – there will be 10% less smokers. That would further ‘denormalize’ smoking.

    2) That legal businesses get to profit from a less harmful alternative to smoking is not a problem, IMO.

    3) The TPD and the FDA’s deeming regs. both ensure that BT (or anyone for that matter) is unlikely to get an open tank system approved for sale/use. Both forms of regulations tend to promote enclosed, non-refillable forms of e-cigs, i.e. (mostly) ineffective cig-alikes.

  • Simon_Chapman

    Andrew, I know it sounds instinctively obvious that reducing smoking is harm reducing. But unfortunately that’s not what the evidence of at least four sometimes very large cohort studies which follow smoking reducers over years have found. Even smokers who reduce by >50% or more show little to no reduction in mortality. I have hyperlinked to those studies that you can read for yourself here https://theconversation.com/spotless-leopards-decoding-hype-on-e-cigarettes-49291 Here’s another http://www.ncbi.nlm.nih.gov/pubmed/12775785 Quitting is harm reducing. Dual use is not. You may be correct about some vapers eventually quitting being harm reducing, but it’s more complex than that. We’d need to know how many vapers stayed in smoking (who might have otherwise quit) in the belief that their reduced smoking was harm reducing.

  • 350 million more smokers today in absolute numbers compared to when Tobacco Control took off in earnest 1970’s. HIV campaigning in the 1980’s has been one of the most successful ones ever, globally. They put harm reduction (when used as intended!!!!!!!!!) at the absolute top of the list of interventions and the fantastic other medical interventions have followed suit. You advocate the opposite approach though no RCT’s have proven efficacy to address this issue. RCT’s as extensively discussed, being a really lousy tool to explain yesterday’s risky sexual behavior after a stint at the pub (or to explain quitting, cutting down, relapsing or what have you in terms of smoking)

  • Karl_Snow

    I hope Clive will answer this comment of yours. I have been waiting almost 3 months now, but no Clive. I think I understand why he doesn’t, not because your reasoning is in perfect order, but because it isn’t. Well I got impatient of waiting for Clive so I will step in though my entrance will certainly not be in his standard, but easy enough. Sorry about that Simon.

    Simon, you seem to like being on the wrong side, don’t you? Of course you know the arguments from tobacco vs e-cigarette industries are quite different, because their products are, or should we say harmful vs not. Simple. Of course, we all know that. Looks like, behaves like, sounds like, but is not the same. But why do you even try to convincing yourself it is? Is it just for the arguments sake or because Clive got you wrong about your unfair statement earlier?

    You continue with the simple reasoning that the words cigarette vs e-cigarett are similar – correct
    Both deliver nicotine – correct again
    Both show hand-mouth activity – correct once more
    Both cig and e-cig want you to stay on nicotine – still correct
    Both want to attract kids – no, no, you sure they do? –

    Oh, the kids are always a very sensitive argument for some people, well, everyone and you know that of course. But all to often a very cheap one if there are no indication shown that we should have to worry about that, thankfully, at least not yet. Or if they wanted would they succeed? Well 50% chance when trying cigarettes, with e-cig it hasn’t been shown (yet) – you failed here.

    And also you forgot to ask the right question, the one kills you and the other does not. – therefore you do not pass and are incorrect.

    You just have to add “feels like” to the earlier “looks like, behaves like, sounds like”; but still isn’t the same.

    The results show you didn’t pass on your own test.

    Well, I think I’ll skip the rest…… it’s too late for that now.

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