I found out about John by reading several messages he posted on the nicotine policy google group, starting with one about the 10 minute video he posted on January 6 on YouTube titled 'The American Lung Association is Lying about Vaping". He also produced another excellent video explaining how WHO failed vaping 101.
It's a good introduction and I encourage our readers to watch it but I'll still ask you to please self-introduce yourselves by briefly sharing some info about your personal and professional background and when and how you got involved in tobacco harm reduction issues.
John Oyston: I was an anesthesiologist for 36 years. In the operating room, I saw smokers undergoing cancer surgery, cardiac surgery, and having legs amputated for vascular disease. I also saw people having routine surgery, like joint replacements, who were at high risk because of the damage that smoking had done to their hearts and lungs. It seemed like, in the operating room, I was just part of a machine putting band-aids on a much larger problem. In 2006 I started to be active in tobacco control. I led the campaign for my hospital to be smoke-free and started a "Stop Smoking for Safer Surgery" campaign. I campaigned for Canada to follow Hawaii and California, and raise the legal age for tobacco to 21. For the last two years I have been studying and writing about vaping as a way to quit smoking.
Q1. I watched again the video. The tone of your voice remains very quiet while I felt increasingly angry at the American Lung Association for refusing to take vaping into consideration as a way to quit smoking. Could it be only because of the funding they receive from big pharma? Did you get any feedback about this video?
John Oyston: So far the video has been seen 3,600 times and garnered substantial praise and little negative comment. It has opened doors for me, as it makes my position on vaping quite clear. The American Lung Association has not contacted me. In some ways I was hoping that they would. If they charged me with libel, proving everything I said is true is a valid defense. But maybe the American legal system is something I should not mess with!
I do not know if there is a link between the ALA getting funding from the Johnson and Johnson foundation (which makes conventional nicotine replacement therapy) and their lying about vaping. Prescriptions for stop smoking medications fell over 70% when e-cigarettes were introduced in England, so J $ J must see them as a threat to their business.
The ALA adopted such an extreme position it was easy to criticize them. If they had been less strident in their criticism it would have required more effort for me to make the case that they were lying, and my audience would have had to put more time and effort into understanding the issues.
Q2. A few days later you attended the 12th Ottawa Annual Conference about smoking cessation (PDF program). You wrote about it in your blog: "My (tobacco control) friends are not talking to each other". Why are so many health professionals dismissing the millions of Canadian smokers who quit smoking by switching to vaping? Why are they scaring the public and especially smokers who now hesitate to use e-cigs to quit as expressed in the recent surveys quoted at the beginning of The Sixth Estate Program you were part of, The Cloud Around Vaping (via Facebook January 21, 59 minutes)?
John Oyston: This whole issue makes me very sad and angry. I know that vapes are not perfect and that they have some real negative health consequences, but they are orders of magnitude better than smokes. We need to find ways to allow easy access to vapes for adult smokers while protecting non-smoking kids from them. That is a moderately difficult balance even with honesty and goodwill on all sides. People on each side of the argument will use any scrap of evidence, debunked or not, to support their cause. If we could clear away the clutter and agree on some basic facts, we could then try to develop evidence-based policy. We could begin by accepting the fact that the USA deaths were not caused by vaping legal nicotine products, that the risk of popcorn lung from vaping is purely hypothetical, that in countries where teens are vaping, teen smoking rates are going down, and that several trials have shown e-cigarettes to be an effective way to quit.
We also need to use language correctly. "Epidemic" refers to an increase in the prevalence of disease. Vaping may be a bad and dangerous habit for non-smoking teenagers, but it is NOT a disease, so there cannot be an epidemic of it. Let's use the word "vape" for the devices used by vapers when vaping. The "e-" before cigarettes is not enough to distinguish vapes from cigarettes. Electronic Nicotine Delivery Systems or "ENDS" is a nice try, but what do you then call a vape full of nicotine-free vape juice? "Tobacco products" is a dangerous US legal fiction. Even tobacco-flavored vapes are tobacco-free, as they use artificial tobacco flavor. This legal fiction allows the "Campaign for Tobacco-Free Kids" to claim that the use of tobacco products in schools is growing rapidly to high levels, when in fact the use of actual tobacco is at the lowest level for many decades.
I used to greatly respect the leaders in Canada's tobacco control community, people like Dr. Peter Selby at CAMH and Dr. Andrew Pipe from the Ottawa Model for Smoking Cessation, but they seem almost willfully blind to the opportunities that are presented to them by e-cigarettes. This seems to be more than the usual inertia of the medical profession in adapting to a new treatment possibility. I am concerned that they might have too cozy a relationship with "Big Pharna". Dr. Selby has an arrangement which allows him to provide free nicotine replacement therapy to qualifying patients and Dr. Pipe runs an annual conference which has partly been funded by Johnson and Johnson for many years. I would love to believe that they have the integrity not to be influenced by financial considerations. However, Dr. Pipe gave a warm welcome to Prof. Stanton Glantz, who he invited to be the keynote speaker at his conference, and during a breakout session he fawned over Stan like a late night talk show host with an "A-list" celebrity. When Dr. Hayden McRobbie presented an alternative viewpoint, Dr. Pipe summarized the presentation in a very unbalanced way.
Q3. You said you had the opportunity to talk (for about one hour) with Stan Glantz who was a guest speaker and is maybe one of the most extreme and influential opponent to e-cigs. Can you tell us about this discussion? After all he basically agrees to everything the ALA claims and you consider lies? Maybe even more.
John Oyston: I met Stan in Ottawa at an event organized by Physicians for A Smoke-Free Canada. A group of us went out for drinks afterwards and he joined my table. The following day he was the keynote speaker at the Ottawa Model for Smoking Cessation Conference and we talked again at a reception after that. Outside of smoking cessation, he is a decent guy. We agreed on many issues related to American politics. After the conference, his wife was joining him for a few days vacation in Ottawa (the world's second coldest capital city). You have to give some credit to a guy from California spending part of his family vacation in Ottawa in February!
Even on smoking cessation, we agree basically on Tobacco 21 ( a reasonable thing to do) and on plain packaging (likely to have a limited effect at this stage). He does not have a problem with me, as a physician, using vaping as a way to get smokers away from tobacco under medical supervision. His main objection to vaping seems to be its widespread availability as a consumer good. He thinks that at a population level it may actually harm smoking cessation, which is odd when smoking rates in the USA and the UK are at historic lows when there is widespread vaping. Between 2015 and 2017 there was a slight uptick in smoking in Canada (perhaps due to legalizing cannabis) but smoking declined in the youngest age groups where vaping is most prevalent.
Eventually, after a couple of glasses of wine, I challenged him on the criticism of his most recent research. He accepts that some of the vapers in his heart attack study actually had heart attacks before they started vaping, but he feels that is a minor glitch that does not detract from the overall conclusion. In fact, he says that he talked to a statistician about it who said that the fact that he got a statistically significant result despite this issue made the correlation stronger. He dismissed Prof Britton's critique of his study on lung disease by saying that maybe some of the people were on the brink of developing emphysema and vaping tipped them over the edge. Overall, he said he used to think that vapes were 25% as dangerous as cigarettes, he now thinks they are 75% as dangerous and trending towards 100%.
Q4. The World Health Organization published on January 20 a Q&A titled 'E-cigarettes: how risky are they?' Would you qualify their position like you did ALA's? Could it be explained by the same reason you proposed for ALA, ie 'follow the money", in this case (for instance) Bloomberg Philanthropies as was discussed in this 2018 academic paper: Balancing Science and Political Economy: tobacco control and global health.
John chose to answer Q4 and Q5 together so here is Q5.
Q5. The content of the WHO's Q&A about e-cigs seems incompatible with the official positions of Health Canada and maybe even more Public Health UK. In France the National Academy of Medicine also criticized WHO's stance against e-cigs on December 12, 2019 (in French).
Do you think those countries should officially contest WHO's approach, beyond the critics already voiced by 3 British experts.
John Oyston: Thanks for the links to the French resources. It is important that truthful information and sensible health policies on vaping come from a variety of sources. We should not put too much weight on Public Health England, as this allows them to be characterized as an eccentric and isolated peculiarity. We need to publicize and promote the positive experiences in New Zealand and in other countries.
The world has a desperate need for an impartial global health organization. Smaller and poorer countries do not have the expertise and resources to develop their own local policies. Even if they did, it should be much better if they contributed their expertise to a global pool, so that the world could develop a co-coordinated response to global threats, such as the corona virus epidemic, and global opportunities such as vaccines and vapes.
Sadly we live in a world where big business can buy media and politicians to create public attitudes and legislation which maximizes their profits. Businesses are designed to return profits to shareholders. Ideally the World Bank and the WHO should be beyond these influences, with stable multi-year funding agreements with governments. They should not have to rely on charitable donations. One would hope that the Bill and Melinda Gates Foundation and Bloomberg Philanthropies each donated $5 million each without any strings attached, but we have no way of knowing. Michael Bloomberg did some excellent work funding countries which were fighting "Big Tobacco" for the right to pass public health laws which would diminish the profits of the tobacco companies. He now seems to have gone on an anti-nicotine battle, suggesting that nicotine use can decrease your IQ by 10 points, based on no evidence. I share his concern about youth vaping, but this seems to have spread into a general anti-vaping war.
Q6. I just looked at the new 2020 Surgeon General Report about smoking cessation and what I don't understand is the claim about "there is not enough evidence that vaping helps smokers quit" while at the same time noticing that many smokers are not told to quit by their doctors. Could it be that health professionals and smokers know very well they should quit and want to but the 'evidence based' tools have not worked for them while the so called 'anecdotal evidence' numbers now millions of smokers who switched, most without any medical help, some of them hiding their switching from their doctor because they feared he/she would disapprove, like told by Michelle Hughes in her rendezvous! How do you feel about that and can you tell us about your quit by vaping program?
John Oyston: I do not entirely understand why traditional smoking cessation groups are not delighted to have a new tool in their battle against tobacco. I totally get concerns about non-smokers vaping. I can understand that there may be an issue if smokers use vaping as the way to get through a day in a smoke-free environment. I am not at all sure that "dual use" is as dangerous as adding the risks of vaping to the risks of tobacco. Some people seem willfully blind to the data that shows that cigarette smoking is heading to new lows, or claim that it was always going to do that despite vaping, rather than because of vaping. Dr. Pipe, for example, dismisses tales of smokers who quit by vaping as anecdotes, and says that "The plural of anecdotes is not data"! Some people seem desperate to believe that some cases of EVALI may have been caused by vaping regular nicotine-based e-cigarettes, even though this is increasingly unlikely.
As I said in my blog post (My (tobacco control) friends are not talking to each other"), imagine the synergies if medical experts on smoking cessation got together with vape shop owners. We could ensure that smokers got the best advice, were warned of the risk of "dual use", were encouraged to cut back on nicotine and quit vaping. We could ensure that they got the best advice about equipment and nicotine and access to other treatments. For example, I think that a combination of nicotine patch plus vaping for cravings could be very effective and further reduce the risk from vaping.
I am trying to set up a medically-supervised "Quit by Vaping": program in conjunction with a vape store. I wrote to 200 local family physicians, asking them to discuss this idea with smokers who had failed conventional quit attempts. I offered to give rounds to them or to see patients in their offices. NOT A SINGLE PHYSICIAN RESPONDED IN ANY WAY!
A recent opinion poll has shown the effect of persistent misinformation on public opinion in Canada. According to a recent Angus Reid poll, in 2018 46% of Canadians felt that switching from smoking to vaping was good for your health. In 2019 the figure is down to 35%. This change has serious consequences. Researchers have suggested that switching from smoking to vaping would save 6.6 million lives in the USA.
If there are physicians in Canada who would like their smokers to "Quit by Vaping" they are in a bind as there are no e-cigarettes in Canada (or the world, I believe), which are made to medical standards and can be prescribed. Equally their are no e-liquids made to pharmaceutical standards. So the only option is to send the patient tot he local vape store and hope that they get good advice from someone who has zero medical training and is a retailer with product to sell at a profit. I was hoping that my "Quit by Vaping" program would provide them with a viable option, but they show no interest in it.
I think many physicians take a fatalistic view and accept that 47,000 deaths from smoking every year are a fact of life, just like snowstorms in a Canadian winter.
Q7. Is there anything else you would like to add?
I hate JUUL. They deliberately misused some rather generous rules on advertising vapes to attract a large number of teenagers to vaping, while doing nothing to promote JUUL as a way fro smokers to quit. This created the so-called "epidemic of teen vaping" which has allowed public health groups to campaign for bans on flavors, and possibly an outright ban on vapes. Health Canada was working on ways to encourage smokers to vape, but they are now distracted by this issue and any attempt to encourage adult smokers to quit by vaping is next to impossible.
I also hate the criminals who sold contaminated THC oil. They directly killed 60 of their customers, but they threw created a firestorm of negative publicity about legal vaping which frightened thousands of vapers back to smoking and bankrupted some vape shops.
At the E-Cigarette Summit in London in November, Professor Tikki Elka Pangestu explained how science is only a small part of the pie when politicians are deciding public policy on an issue (Vimeo video). This is very true about vaping. A recent Angus Reid poll has shown hat 56% of Canadians now disagree with the statement that "Switching from Smoking to Vaping is a good move for your health". When Health Canada did surveys on putting information about vaping in cigarette packages, many people said that they were not interested in hearing this message.
Hon Lik (the inventor of modern e-cigarettes) should be a global public health super-hero. There should be statues erected to honor him. He should be in the same exalted category as Fleming, Jenner, Salk, Banting and Best. If we manage his invention correctly, and use it as he intended, we could save the lives of most of the eight million people who die every year by meeting their nicotine needs by using cigarettes. It would be tragic if we allow bad actors to mess up this opportunity.
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