May 18, 2018 Rendez-vous #9
with Ron Borland
Ron is the Nigel Gray Distinguished Fellow in Cancer Prevention at Cancer Council Victoria in Melbourne (since 2004).
Thank you Ron for accepting our rendez-vous.
May I ask you to introduce yourself by giving us some personal background and telling us when and why you started to consider electronic cigarettes as a method of tobacco control (to use the title of your editorial in the BMJ in September 2011)?
Ron Borland: I have been working in tobacco control for over 30 years now. Most of my research has either been around the effects of policies on smoking cessation, or on the development and evaluation of mass disseminated smoking cessation interventions.
In my early years working in the area I was struck by the need for greater regulation of tobacco in the context of people working with other drugs who are working towards decriminalisation, and thus reduced strength of regulation. This led me to argue that there was some sweet spot for any particular product which minimised its use, or abuse, but allowed it to be effectively regulated, something that prohibition effectively precludes.
In the mid-90s I became aware of the emerging evidence that Swedish snus was far less harmful than smoking and this raised in my mind, as in others, the possibility of shifting smokers to less harmful alternatives. This started a systematic exploration of possibilities for shifting smokers to less harmful alternatives, one result of which was the development of a proposal for a regulated market for tobacco products, published in Tobacco Control in 2003.
Since then, harm reduction possibilities have been a constant theme of my work.
Early on, I was attracted to the possibility of snus as a substitute because it is a less social activity than smoking and less publicly noticeable, so it would be less likely to create the social conditions that might encourage non-smokers to take it up as a less harmful alternative to smoking. I first became aware of electronic cigarettes through a conversation with Murray Laugesen who had discovered the original Ruyanelectronic cigarette, and was aware that it was exciting some consumer interest. He conducted what I believe was the first research study on the topic. (I understand Murray is in failing health and it would be terrific if you were to consider a rendezvous with him as he has been one of the great minds in the field.)
My initial reaction to the e-cigarette was dismissive based on the history of Eclipse, Accord, and the various other attempts by the tobacco companies to market similar products. However, once I became aware of the surprisingly high level of consumer interest and the emergence of a vibrant vaping community who are driving further innovation, it seemed to me that we had the basis of a viable substitute for high toxin, high addiction potential, cigarettes. The more these products develop the more likely it is that they will be, or become good enough to replace smoking. However, it is also very clear that he early versions were little or no better than other nicotine replacement products, although appealing to a different sub-section of smokers.
Q1. I got part of my training in tobacco control advocacy from Nigel Gray (in the early 90s) and he was widely respected as exemplified in this tribute and farewell by WHO-TFI upon his death in December 2014. A few months earlier he had co-signed (as you did) a letter to Margaret Chan about tobacco harm reduction that ironically does not reflect the present orthodoxy at WHO. Could you tell how you think he got to this position and if you discussed with him the divide of opinion within the tobacco control community that remains as of today?
Ron Borland: Yes, I had a number of conversations with Nigel. Many of these were in the context of pulling together our jointly authored paper, one that Nigel had started out working on alone, on research questions around the implementation of articles 9 and 10 of the FCTC. This was published in Nicotine and Tobacco Research in 2012.
Nigel, as can be seen in his work with WHO and several publications, had a very strong interest in reducing toxicant levels of cigarettes. He saw the emergence of alternative products as a logical extension of this work. Without wanting to verbal the dead, my recollection is that he was less optimistic in some about the potential of electronic cigarettes and remain concerned about the extent to which it might be a side issue.
Nigel, as you're probably aware, was the rare individual who is prepared to publicly state when he was wrong, as he did in his mea culpa about his role in encouraging the proliferation of so-called light cigarettes, with insufficient focus on the fraud of filter ventilation. My sense is that he was more comfortable working towards the harm reduction focus on existing cigarettes, than embracing the possibility of extremely low harm alternatives. Nigel also had a healthy distrust of the industry, as you would know having sparred with them frequently. I think this coloured his caution. As to the Chan letter, Nigel didn’t need any urging to sign, and never regretted it as far as I know. He was sure this was the broad direction to go, but shared an uncertainty as to how it would play out.
Q2. Another famous tobacco control advocate based in Australia is Mike Daube who recently published an articleTobacco in Australia: time to get back to basics, that leaves no room for tobacco harm reduction. This article raises many questions but what do you most agree and disagree with?
Ron Borland: I disagree with most of what Mike has to say except for the more general point that we do need to continue with the current range of strategies and, where there has been slippage, to reverse it. (NB: I haven’t read his piece in detail, merely scanned it). Where I strongly disagree is in the implication that this is all we need to do. I am firmly convinced that unless we have realistic alternatives for smokers who get positive value from smoking, far too many will remain unwilling or unable to quit smoking.
I started working in tobacco control for the Cancer Council (then the Anti-Cancer Council of Victoria) in 1986, a year or so after the first major anti-smoking campaigns. In Victoria, there has been at least one mass media campaign every year since 1985.
In Australia more generally it is now over a decade since we effectively banned smoking in all major forms of indoor spaces, there is virtually no advertising, and it is coming up six years since cigarettes have been sold in standardised packaging. Currently cigarettes cost around a dollar or more per stick.
All of these activities have driven down smoking but there is still a significant minority of people who continue to smoke, and around 1/5 of all young people take up smoking.
This data leads me to the conclusion that the current range of strategies are inadequate.
There is a significant section of the population who are drawn to nicotine use, and/or having been drawn to it find themselves unwilling or unable to quit. I spent a lot of time studying the difficulties smokers face in successfully quitting. I am convinced that for many quitting smoking is a close to impossible task, at least without the help of some substitute product that provides at least some of what they get from their cigarettes. Given that the best estimates are now that two in three long-term smokers will die prematurely as a result of their smoking this means a lot of potentially preventable premature death and associated morbidity.
There is compelling evidence from Sweden, and increasingly Norway that the use of their clean smokeless (snus) products is not associated with any major cause of premature morbidity, at least among otherwise healthy individuals. While it is not without harm, the health of Swedish men, the group who have been using snus the longest, is consistent with that low smoking rates not their much higher nicotine using rates.
Recently I helped Lars Ramstrom analyse some Swedish data demonstrating that snus has both led to a prevention of the uptake of daily smoking and has facilitated cessation from it. Snus, at least, far from being a gateway to smoking has restricted the entry gate but loosened the exit gate.
Returning to the question, I see no prospect of getting smoking rates down below about 8% in Australia with the current mix of strategies.
Virtually the entire reduction in smoking that's been achieved this century has been through our success in reducing uptake with very little due to improvements in cessation. The current range of strategies is simply not enough.
Ken Warner has just published in Nicotine and Tobacco research a plenary piece arguing that we should separate how we think about the issue from how we feel about it (listen also to the webinar). I am in total agreement with him on this.
Indeed in 2004 I published a book on hard to maintain behaviour change which characterises problems like smoking as ones for which there are good rational reasons for stopping but strong competing feelings that stop many smokers succeeding. In this regard, I think many in tobacco control are caught in the same kind of dilemma.
It is difficult to move away from the simple “smoking is bad”, “the tobacco industry is evil”, and therefore anything they do we should be against, which is a simple and easy to follow as well as being a morally uplifting framework to take.
Unfortunately, the world is much more complex, and if we accept that in the foreseeable future there is going to be a market for nicotine, then inevitably we need to deal with, and regulate those who seek to market it. This would be much easier under a regulated market model, but this idea has never had anywhere near the kind of support that would be necessary to make it a possibility. In my opinion, a lot of the opposition to harm reduction is grounded more in feelings than on hard analysis.
As a scientist, I continue to be struck by the poverty of evidence and in the systematic distortion of evidence put forward in arguments about the potential downsides of vaping and other alternative products. It is true we don't know with any certainty what the long-term effects of vaping will be. However we do know that with current technologies it is possible to vape with very low levels of toxic exposures, at least two orders of magnitude less than for smoking for the vast majority of toxicants of concern.
If we try to interpret this data using the science of toxicology we are inexorably led to the conclusion that the health risks are going to be substantially less. While a number of people, most notably Stan Glantz, have questioned the degree of reduction, in some cases offering unsubstantiated alternative estimates, nobody has come up with a coherent, science-based argument to seriously question the no more than 5% of the harms estimate of the group convened by David Nutt. The modelling that has been done indicates that there are likely to be net health benefits unless the risks of vaping are in excess of 30% those of smoking, and I can see no plausible mechanism by which this could be predicted. Thus I think in all probability there will be positive effects, most likely major ones.
I do accept, however, that the widespread introduction of low toxin consumer acceptable nicotine products may lead to an increase in total community nicotine use.
The recent upsurge of interest in Juul in the US is consistent with this concern, as at least some of the interest is from young people. If one was to assume that nicotine use had no redeeming benefits, this would be an unequivocally bad thing. However, for some people at least, nicotine may in fact serve useful psychological functions, helping to regulate both mood and arousal, something society has no concerns about caffeine performing.
At this point, I think some degree of caution is sensible, and I think we should be discouraging youth uptake of nicotine as strongly as possible. However, I don't believe that there is a public health case for preventing access to the cleanest possible forms of nicotine to adequately informed adults.
Q3. There are constant requests to rise taxes on tobacco and the price of cigarettes is fairly high is Australia (one of the highest in the world?). I have become concerned with the disproportionate prevalence of smoking by socio-economic status (or here). Among Australian current smokers the prevalence rates are: unemployed 26%, unable to work 33%, most disadvantaged 20%, 2nd quintile 17%, 3rd 15%, single with dependent children: 31%.
What is your assessment of those data? I should add the same socio-economic disparity exists in other countries with similar income (see point 1,7.3).
Ron Borland: I am also concerned about the impact of the extremely high cigarette prices in Australia on the poor. In my view, the magnitude of the illicit trade is being exaggerated, as all the surveying that we have done, and I have seen indicates much lower levels than that claimed by the tobacco industry. However some of the economic burden is being avoided through accessing illicit tobacco, most common, at least anecdotally, amongst the extremely poor. There are also concerns of the extremely poor scrounging butts and rolling them up into new cigarettes or relighting them as a way of getting nicotine. Such activities are likely to be associated with increased acute health risks as well as being personally demeaning to the people who are feeling the need to engage in these activities.
Philosophically, I'm a left-wing libertarian, thus I believe that the role of government in policing individual behaviours should be severely limited. I accept that there is a point where the harms are so great that society has an obligation to step in, but only in the most extreme cases are coercive methods warranted. Thus I believe it entirely appropriate to take quite strong, non-coercive, measures to discourage smoking, particularly creating societal structures which make smoking more difficult, and taxing such that some of the external costs of smoking to the community are returned. However, I do not believe that the same level of societal restraint, or anywhere like it, is justified for the likely much lower risks associated with use of clean forms of nicotine
Q4. You submitted an opinion to the Tasmanian Government before they adopted new tobacco regulations, quite restrictive toward electronic cigarettes and products containing nicotine. Meanwhile the smoking prevalence for low income people in Tasmania is double (26%) what it is for people with higher income (2014) and they find it harder to quit. What do you think of the new regulations?
Ron Borland: I haven’t studied them, but given my other comments here, I am not supportive
Q5. What studies should be undertaken to try to clarify the potential benefits or dangers of nicotine based substitutes? Are such studies taking place now in Australia?
Ron Borland: Unfortunately, there is not much happening to try and monitor whether medium and long-term harms do emerge from vaping (pretty much anywhere as far as I can see). Notably, there are no calls for such research from those who suggest that serious adverse effects might occur.
In my view, we do need an international cohort study to document possible long-term effects, following groups of continuing smokers; long-term smokers who switch to vaping; long-term smokers who have quit nicotine altogether; and cohorts of young people with varying smoking and vaping histories.
I think it plausible that substituting vaping for smoking will not provide all the health gains that quitting smoking might, but this is by no means certain. Among the young, while I think it more likely than not that a history of vaping independent of smoking will be associated with some adverse consequences, I don't think this is a foregone conclusion, nor do I think that the level of those adverse effects will be necessarily greater than the potential benefits that those individuals might gain. However, until the situation in this regard is clearer, it is wise to be cautious.
Q6. Is there anything you would like to add?
Ron Borland: I think the rise of alternative nicotine delivery systems is inexorable.
Whether this is mainly Heat not Burn (see what is happening in Japan) or vaping (see Juul in US) or some combination, which may also include snus, is unclear to me at this point. But the genie is out of the bag.
Like King Canute, elements of the tobacco control movement might be able to temporarily slow the tide ( or put the genie back in the bottle, to mix metaphors), but I very much doubt whether they'll be able to stem it completely.
Given the highly likely net benefits to smokers of switching to these products, any delay caused will be costing lives in the short to medium term. This remains true even of the long-term consequences for new vapers are less positive than the estimates suggest. If this latter undesirable scenario were to be the case, it would be appropriate to reapply some of the strategies that we've used to drive down smoking rates to try to control the problem (still likely far less than from smoking). Given that we now have enough evidence to know that orally administered clean nicotine has few major adverse effects, if vaping turned out to be too harmful, and could not be sufficiently cleaned up, then attempting to move communities beyond Scandinavia to smokeless tobacco might also be part of the solution.
Some people are against vaping as a consumer activity, but are prepared to support it as a therapeutic good, if it should be could be shown to be an effective cessation aid. On the face of it, this is a reasonable position. However, it has in fact been tried in England and has failed. The reality is that currently innovation is moving too fast and a second reality is that these products are being used as consumer products and there are real problems associated with trying to regulate under therapeutic goods frameworks products that are being used recreationally rather than for a specific therapeutic purpose.
The world has changed, there now are commercially viable alternatives to smoking. Like it or not these products are being used as consumer products.
We should be working to develop the regulatory framework to exploit this to get rid of smoking as a mass consumer activity as rapidly as possible. We need to ensure that vaping products are covered by adequately strong consumer standards and to do this as rapidly as possible.
Given the lack of problems with acute toxicity, concerns about the potential long-term effects of some additives, in this case largely the flavourings, needs to be looked at carefully, and where necessary restrictions could be put in place. That said, a lot of the concern is overstated.
For example, there has been great concern about the presence of diacetyl, a compound linked to a disease known as popcorn lung, being present in some flavourings. However, as I understand it the levels detected are lower than the levels found in combusted cigarettes, and no case of popcorn lung has been recorded from smokers, absent other environmental exposures. In some cases, it may be prudent to advise vapers to vary the flavours they vape, a strategy which would reduce the risk of long-term exposures to specific chemicals from the flavourings.
As a general principle, I am against "wolfs in sheep's clothing", by which I mean products with some harm potential being disguised to taste like innocuous foodstuffs; for example, artificially sweetened alcoholic beverages. I think society does have a right to restrict products which have the capacity to mislead or distract users from their psychoactive effects, if there is a potential for harm.
Given the uncertainty about the harm profile of vaping products, I think a case can be made for prohibiting flavours that can be shown to differentially attract young people, and similarly there should be restrictions on promotional material that is designed to, or has the effect of, promoting the desirability of vaping to non-vapers, apart from it being a better option than smoking. Some of those opposed to greater availability of vaping cite the precautionary principle.
I believe it is of perversion of this principle that the uncertainty associated with the magnitude of the likely benefits from vaping could be used as an argument to slow its introduction in the context that what it is potentially replacing is certainly causing huge amounts of harm.
To finish on a more positive note, I think there is an increased realisation that vaping and associated products are not going to go away, and an openness to seek solutions.
In this regard, it is important to note that most of the groups identified as being opposed to vaping, are doing so on the basis of caution and the need for more evidence, few have taken position of absolute opposition.
I think people are realising that smoking rates are continuing to decline in places where vaping and other activities have been most prominent, and indeed may be declining at faster rates than elsewhere. This should reassure people that any gateway affects are being dwarfed by other factors because they, if they exist should be leading to increases not decreases in smoking.
As we come to realise that the most feared consequences are not happening, I think people will be able to feel much better about the idea that substitutes are at least a good interim solution to the tobacco control problem.
Thank you Ron for having taken the time for our rendez-vous.
Comments