April 9, THR-rendez-vous 3, with Louise Ross
Thank you Louise for accepting our rendez-vous. May I ask you to introduce yourself?
Louise Ross: Until very recently, I was the Stop Smoking Service Manager at Leicester City Council. Previously part of the National Health Service, we moved to local government in 2015, but kept the same successful format to deliver the service to people who were (often literally) sick of smoking. We became very interested in e-cigarettes and vaping in late 2013, putting our instinctive interest into practice in 2014. There’s more from me as a guest on The Counterfactual website but more importantly, do read Clive’s fantastic blog for in-depth, punchy analysis
Q1. I just read some ads about Vapril in the UK and Dr Christian Jessen's endorsement. I found it interesting as in my most recent conversations with vapers they repeatedly said most physicians (or dentists for that matter as I recently talked with mine) are unwilling to say publicly e-cigs can help smokers quit using combustibles and are much less dangerous. What has been/is your experience?
Louise Ross: My experience is the same. When I encounter a clinician who is willing to talk positively about the benefits of switching from combustible cigarettes to electronic cigarettes, I almost jump for joy.
My own encounters both as a patient and as a public health professional leave me amazed that there is such ignorance, nervousness, suspicion and open hostility towards what we can see clearly is a less harmful product. I think some of this comes from a remoteness among clinicians about smoking and the need for nicotine. Because most professionals nowadays don’t smoke, they can’t understand why people who
do smoke can’t just ‘get over it’ and pull themselves together. Our own Chief Medical Officer said this at a conference in 2014, before going on to say that she could not support the notion of e-cigarette use, claiming that she hadn’t seen any evidence to support their use. Sadly, she left the conference as soon as she had delivered her damning verdict; if she had stayed she would have heard a great deal of emerging evidence, and it might have got her thinking that a second look wouldn’t go amiss. I suspect this is replicated among many in the profession, although the new NICE guidelines may help to change some minds.
Health practitioners who want to know more about the use of ecigs to stop smoking will really benefit from reading the briefing prepared by the National Centre for Smoking Cessation and Training. The Centre (NCSCT) has also produced an e-learning module on the same subject and some great films to illustrate the facts about vaping, see for example The Switch.
Q2. You mention a very frustrating episode that took place in 2016 when you had to endure and the audience had to hear from the person who was speaking against e-cigs a litany of very negative (and false) assertions. How do you assess the situation today? Do you think there is less misinformation/distortion/ confusion?
Louise Ross: All the time the media jump on cherry-picked research that spreads doubt and confusion, or tell a part-story, based on flawed research, that is easily spun into a shock-horror headline, false assertions will continue to circulate among professionals and the public alike.
As an example, the advisors at my stop smoking service get asked weekly about popcorn lung, the fear of which seems to have embedded itself in the mass psyche of the population, both smokers and non-smokers. Interestingly, we can clear up those myths when we are talking one-to-one with a service user; what is much more alarming is the way influential physicians can discourage their patients forever from switching from smoking to vaping, by virtue of the authority with which they speak.
One of the last conversations I had with a patient was with a lady who had to have surgery for a vascular condition affecting her legs. She had been a smoker for years and had proudly told her consultant that she had switched to vaping. He declared that vaping was just as dangerous as smoking, and that she must stop using her vaporiser. She went back to smoking. I told her frankly that he was misinformed, and she, understandably, asked me who she should believe, the consultant who was going to do her operation or someone on the end of a phone she had never met.
Q3. I must admit I am still concerned about the addictiveness of nicotine, especially for young people. It takes time to rehab from years of demonization and youth focus and some troubling stories (like this one). Is this a real issue to be concerned about? How best to deal with it?
Louise Ross: This article is a great example of subtle misinformation. There isn’t space here to analyse it, but it is full of misleading and factually incorrect information and is exactly the sort of item that fills the reader with alarm.
The majority of young people who vape regularly (not just experimental use – remember most young people try stuff, but don’t go on to regular use) started as smokers. Regular vaping among never-smokers remains rare. Clearly though, this needs on-going surveillance, and in the UK, Action on Smoking and Health (ASH), and Cancer Research UK (CRUK), are doing just that.
Adults who have used our stop smoking service, and members of the public I have spoken to about their use of different strengths of nicotine, report that they tend to reduce the strength they use once they become familiar with vaping techniques, and often alternate general use with low or zero strength juice, simply enjoying the feel of the device and the hand-to-mouth action.
Q4. Another issue that has been troubling me is the constant emphasis on raising taxes on cigarettes while the prevalence among the people with low (or no) income appears stable so they don't get any health benefits and are financially impacted. I know the industry has been claiming for years about how regressive the tobacco taxes are but now that (in many countries) prices are much higher than they were and the prevalence is still high for the poorest people, what should be done? I should add I wonder about e-cigs and homeless people: are e-cigs a viable option for them?
Louise Ross: This is a hot topic right now, with many views expressed on all sides.
What I’m concerned about is the notion that e-cigarettes should be taxed in the same way as tobacco cigarettes (a policy aspiration and indeed a reality in some countries, fortunately not the UK, which appears to lead the world in ecig-friendly policy-making).
Countries which escalate the tax on e-cigarettes inevitably drive smokers back to smoking, or stop them transitioning in the first place, because they rob smokers of the financial benefit of switching. Currently, our service users say that they spend about 10% on vaping compared with what they used to spend on cigarettes.
When you hear how their health has improved too, it is hard to imagine why a country would want to deny that opportunity to its population, other than seeing a nice revenue windfall from a novel source.
On the question about ecigs for homeless people: yes, our service has made some headway in this area, and other services/researchers are doing parallel work on this. In my opinion, it contributes primarily to harm reduction and may only lead to a complete switch if the individual is 100% determined to never smoke again. This is because the societal and environmental pressures on people in this social group leave them very vulnerable to relapse. I believe that it is a worthwhile aspiration though, and we have been very grateful to the local retailer which has supported our initiative generously by providing heavily-discounted kit for homeless service users.
Q5. You have been in this field a long time. You have now retired. Do you see a new generation of advocates coming in to keep up the good fight and win?
I also wonder about the international aspects of the tobacco harm reduction 'debate'. Do you see coordination between advocates for harm reduction at the international level?
Louise Ross: I am just a tiny cog in a huge wheel, and there are many people much more influential than me, and certainly cleverer, who are making a difference. I feel privileged to be part of a virtual international group of advocates, consumers, researchers, scientists and influencers who share a desire to promote the development and availability of safe harm-reduction nicotine.
You can be assured that there is much going on in this field, and anyone who wants to know more should consider attending the Global Forum on Nicotine in Warsaw or join the New Nicotine Alliance (new alliances are starting up worldwide).
Q6. Is there anything else you would like to add?
Louise Ross: In conclusion, I’d like to share one of my favourite aphorisms, which I think applies so well to this unique battle for the truth: "They tried to bury us. They did not know we were seeds" (Mexican proverb).
Thank you Louise for having taken the time to answer our questions.
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