Wales This Week, Smoke Without Fire?

July 29, 2014 by B 16 Comments

First please go and sign the petition against the proposed ban on vaping in public places in Wales.

“Wales this week” has demonstrated one thing beyond doubt. They seem to be incapable of balanced reporting, and their lack of research makes a bad job worse. This is tabloid journalism and it demeans the vapers who took part in the program in good faith. Here’s the link to the program.

We start with the Welsh minister for health stating that there is ’emerging evidence’ that states that the vapour from vaping could be harmful to bystanders. There is no evidence that this is the case; any study that has tried to argue that there is has been proven to be not scientifically rigorous. In counter to that point I submit this review on the available evidence:

“Current state of knowledge about chemistry of liquids and aerosols associated with electronic cigarettes indicates that there is no evidence that vaping produces inhalable exposures to contaminants of the aerosol that would warrant health concerns by the standards that are used to ensure safety of workplaces. However, the aerosol generated during vaping as a whole (contaminants plus declared ingredients) creates personal exposures that would justify surveillance of health among exposed persons in conjunction with investigation of means to keep any adverse health effects as low as reasonably achievable. Exposures of bystanders are likely to be orders of magnitude less, and thus pose no apparent concern.” [Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks. Igor Burstyn] Emphasis mine.

Then we have the results of a poll which suggests that “more than half” of the respondents said they supported a ban on vaping in public paces. How many people were polled? Who were they? How were they selected? Who conducted the poll? What was the wording of the questions used? A nice soundbite, but it has absolutely no substance.

At 40 seconds in we hear that a vaper “claims” ecigs have saved his life. I’ll accept that they have to present vaper testimony as anecdotal, but actually some experts agree, and Professor Robert West would have backed him up with some nice counterbalancing expert opinion at this point.

Now we have the statutory exploding ecig tabloid soundbite. I’ll come back to this point later.

“This may look like a scene from the past, smoke filling the air as people enjoy a drink in the pub” It’s designed to be inflammatory, but I wonder how many people notice one crucial difference. The vapour isn’t filling the air. The air itself looks clear; there is no residual haze. No matter how big those puffs of vapour are there isn’t the same effect. Were any non vapers in there interviewed to ask what it smelled like? Was it unpleasant to them? We don’t know. Just a shot designed to equate vaping with smoking. The “clean air” act was put in law from scientific research which suggested that second hand smoke was harmful. As there is no evidence to include vaping in “clean air” legislation on health grounds (whatever the Welsh Health Minister says) there is no justification for banning it in public places.

The soundbites from the vapers were fine, but cut short. Most of them tried to explain tobacco harm reduction; the idea that switching to a SAFER (not 100% safe; none of us say it is) alternative to lit tobacco has health benefits.

“The Health Minister is convinced they normalise the act of smoking.” Vaping cannot normalise smoking, because it is not smoking. vaping normalises not smoking. It’s like saying sugar use normalises cocaine use. Like banning water because it looks like gin and vodka. It’s another diversionary campaigning tactic without any evidence to back it up. Utterly meaningless, and with no foundation in truth or fact. “He also says that there is not enough evidence to assume that they are completely safe.” Which misses the point entirely; no one is suggesting that vaping is 100% safe. Nothing is 100% safe. They are SAFER than smoking. We are arguing for harm reduction by switching to a SAFER alternative.

Drakeford says that he “has to proceed on the precautionary principle” But he is both misinterpreting and misapplying that principle.

From the EU guidance to applying the precautionary principal,

The precautionary principle must also seek balance. It must balance out the harm of regulations imposed with the possible harm of no regulations;

Where action is deemed necessary, measures based on the precautionary principle should be, inter alia:

• proportional to the chosen level of protection,
• non-discriminatory in their application,
• consistent with similar measures already taken,
• based on an examination of the potential benefits and costs of action or lack of action (including, where appropriate and feasible, an economic cost/benefit analysis),
• subject to review, in the light of new scientific data, and
• capable of assigning responsibility for producing the scientific evidence necessary for a more comprehensive risk assessment.

To which Clive Bates says this:

“the key guideline is the 4th in the list above: the requirement to apply a symmetric assessment of risks and benefits arising from both regulatory intervention and non-intervention. In other words, if a regulator wants to come down heavily on a product like e-cigarettes because of hypothetical dangers, it has to take into account the lost benefits that might arise if it bans, restricts or otherwise reduces the positive potential of the product.  For e-cigs this is particularly salient as the benefits are to health, not just economic.”

There is no “pile of evidence which suggests that [vaping] may cause harm in the future.” There is a great deal of evidence which suggests that there is a very small risk associated with vaping.  A simple chemical analysis of the system will tell you that. In rebuttal of this point I submit this:

Authorities concerned about our health often request marketing of electronic cigarettes be banned until their safety is proven. To prove safety, one has to prove the absence of harm. So we encounter similar difficulties as described above for proofing the absence of Nessie.

What evidence is required for declaring electronic cigarettes as “safe”?
Electronic cigarettes may be regarded as safe if users don’t experience toxic effects. Since millions of users haven’t suffered any damage so far, this criterion appears to be met. However, there could be subtle chronic effects that become apparent only after a while. To account for this possibility, health advocates ask for long-term studies. But what is “long” (1, 5, 10 or even 20 years?) and for what kind of effects should we look for? [Safety of electronic cigarettes and the Loch Ness Monster Bernd-Mayer]

“In America research has been conducted that suggests that vapour could be harmful to the user” Yes, there have been a few studies which suggests that this could be the case, mostly by Stanton Glantz and his disciples. For a good insight into why policies should not be based on this research I turn to ECITA’s blog. See this post and this post to begin with. Stanton Glantz has also been called out on the so called “gateway” effect. His research has been discredited as utterly inaccurate even by the ACS: Stanton Glantz is such a liar that even the ACS balks: his latest ecig gateway “study”.  For a brilliant analysis of the flaws in that study please also see Clive Bates on the subject.

I support a ban on selling to under 18s with reservations. We give out nicotine patches to 12 year olds. At what age should harm reduction in smokers be allowed to start? Beware the unintended consequences of good intentions.

I agree with the GP’s stance, but think that here is where the idea of harm reduction should have been argued. If smokers switch to a safer alternative, there are health benefits:

Stated estimates for how much less risky ST is compared to smoking vary somewhat, but the actual calculations put the reduction in the range of 99% (give or take 1%), putting the risk down in the range of everyday exposures (such as eating french fries or recreational driving), that provoke limited public health concern. Even this low risk is premised on the unproven assumption that nicotine causes small but measurable cardiovascular disease risk (as do most mild stimulants such as decongestant medicines, energy drinks, and coffee), since such risks account for almost all of the remaining 1%. Perhaps just as important, even a worst-case scenario puts the risk reduction at about 95%, meaning that any scientifically plausible estimate shows THR has huge potential health benefits. There is no epidemiology for the new electronic cigarettes and very little useful epidemiology for assessing long term use of pharmaceutical nicotine products. But since most of the apparent risk from ST comes from nicotine, and the other ingredients in the non-tobacco products are believed to be quite benign, we can conclude that the risks across these product categories are functionally identical from the perspective of THR.

[…]

One common misleading claim is a risk-risk comparison that has not before been quantified: A smoker who would have eventually quit nicotine entirely, but learns the truth about low-risk alternatives, might switch to an alternative instead of quitting entirely, and thus might suffer a net increase in health risk. While this has mathematical face validity, a simple calculation of the tradeoff — switching to lifelong low-risk nicotine use versus continuing to smoke until quitting — shows that such net health costs are extremely unlikely and of trivial maximum magnitude. In particular, for the average smoker, smoking for just one more month before quitting causes greater health risk than switching to a low-risk nicotine source and never quitting it. Thus, discouraging a smoker, even one who would have quit entirely, from switching to a low-risk alternative is almost certainly more likely to kill him than it is to save him.  [Source] Emphasis mine.

Rob Heyes’ testimony isn’t an uncommon story. My story is similar, and for more anecdotes you can look at Clive Bates’ blog again.  Where is the humility, where is the empathy? I also agree with him on the harms that could be caused by banning vaping in public places; the benefits to normalising vaping include the ability to vape to get round smoking bans. I’m one person who first tried vaping for just that reason, and I’ve now switched completely. Every day up and down the country vapers are approached by smokers and asked about our gear. I can think of five such stories that I’ve heard in the last month; again beware the unintended consequences of good intentions. The wrong message would be put out by banning vaping in public spaces. The thin edge of the Spanish problem when vaping was discredited there.

Mentioning EU standards and showing juice being made in a clean room was good. A great deal of Chinese made juice is also manufactured to this same high standard. Remember that the e cigarette was first invented in China which is why China dominates the market. Just because it’s Chinese, it does not follow that it is poor quality. There is juice produced in every country that is also of a low standard; Trading Standards do enforce the 17 EU regulations that apply to e cigarettes in the UK. ECITA guidelines keep UK vendors within the law. This is good practice. If you don’t see proper labels and child proof caps on e liquid you see for sale, then go elsewhere and report the trader.

The reporter then buys E liquid from a market trader and asks for OILS. E Liquid is not an oil, contains no oil, and should never be referred to as an oil. Oils are harmful if inhaled. This makes me certain that this reporter did not do sufficient research. They took it to a lab and the “expert” tells us that it’s very toxic, giving an old and disproved LD50 figure. E Liquid in the concentration that was bought on that market stall is as toxic as washing up liquid. Far less toxic than was stated in the program. This is a serious error and should be corrected. There were no contaminants and the nicotine levels were accurate; as I’ve already said Trading Standards should enforce this.

The “new legislation” coming in in 2016 as things stand won’t regulate all nicotine containing products as medicines. This refers to the TPD, under which we see a “twin track” approach recommended to member states. It is a disaster, and vapers all over the EU are fighting it. For more about what it will probably do see my post. When vaping is outlawed only outlaws will vape.

Across the border in Pembrokeshire there should be concerns about battery safety and the suitability of charging units. This is not an e cigarette specific problem. One quick google search pulled up two recent similar incidents not e cigarette related. One was a phone charger on a bus, and the other a mobile phone. These are isolated cases. Meanwhile a quick google search pulls up the 2011 information on smoking related fires in the UK:

Habits such as smoking whilst drinking alcohol in the home or lighting up in bed are responsible for one in three (36 per cent) of all accidental house fires resulting in deaths. [Smoking time bomb: cigarettes the most deadly cause of house fire fatalities]

Isolated battery charging mistakes do not warrant scaremongering over reaction in the press. Please could we have responsible reporting on this aspect of e cigarette safety. Responsible vendors do disseminate this information and in fact e cigarettes are operating as a harm reduction tool in this area too. Trading Standards will also enforce this.

It is difficult to imagine what guidelines Pembrokeshire Trading Standards will put out regarding the TPD; It hasn’t been included in UK law as yet, and having read my blog on the subject you’ll understand that I can’t see a single product on sale today that complies with the TPD.

The letter to the WHO is mentioned. You can read it here, and also read a guide to it here. It is worth reading rather than just being mentioned. The expert you see speaking at the conference on e cigarettes is Professor Peter Hajek; another man who is very much worth listening to. Here you can see him speaking at another conference, this year’s inaugural Global Forum on Nicotine,

The last word is given to Drakeford and he tells us that he is not trying to ban e cigarettes; he is simply seeking to ban their use in public places. I’m going to give the last word here to Clive Bates, who was fighting for my right to a safer alternative to lit tobacco long before I knew that vaping existed. This is from his post: “Turning the tables on public health – let’s talk about the risks *they* create”

I’ve had enough of the one-sided conversation about the risks associated with e-cigarettes… poisons, gateways, renormalisation, fires, explosions, MRSA, pneumonia, dual use, undermining tobacco control, nitrosamines, anti-freeze, particulates, heavy metals, dead dog, dead cat…. blah blah blah.

ENOUGH! The public health establishment is conspicuously failing to recognise the risks associated with its preferred policy responses to e-cigarettes: with not having e-cigarettes, with banning snus, with prohibiting vaping in public places, with confusing people about risks, with controlling everything.  They carry on as if these risks are zero or somehow not their responsibility – but they are all plausible and all end in more smoking and more cigarette sales. We need to press them much more assertively on the risks they create and the harms their ideas may do:

• “do you accept these risks are plausible and can you see how and why they might arise?”
• “what evidence do you have regarding these risks?”
• “what make you so confident your policy ideas will not cause more harm than good?”
• “at what level of risk would you stop advocating these policies, or at least call for more evidence?”

For almost every policy idea there is for regulating harm reduction, there is a realistic risk that it will make things worse for health. And for almost every theoretical risks from vaping, there is a more plausible theoretical benefit.

[…]

Banning vaping in public places. Organisations like the BMA, Public Health Wales and Faculty of Public Health seem to have never considered that their policy in favour of banning vaping in public places may diminish the value proposition for switching to e-cigarettes from smoking and cause more smokers to persist with smoking. Have they ever accepted that sending vapers outside to join the smokers may cause more relapse to smoking? Where is their account of the potential lost benefits that might arising from normalising vaping in public places, and thereby encouraging more smokers to switch? They are totally silent on these points, have no evidence to suggest these risks are nugatory and accept no responsibility for the harmful consequences that might arise.

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