Excellent interview from Ashtray Blog

By: James Dunworth

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“In the latest in our series of interview with experts on electronic cigarettes and/or tobacco harm reduction, Paul Bergen interviews Clive Bates, former director of Action on Smoking and Health.

Clive Bates has had a varied career in the private, public and not-profit sectors. He was the Director of London-based campaigning organisation Action on Smoking and Health from 1997 to 2003. He no longer works professionally in the public health field and specialises in energy and the environment. He has no conflicting interests or affiliations in health organisations, pharmaceutical companies or the tobacco industry, but continues to take a personal interest in public health policy. In this interview, he is speaking strictly in a personal capacity and not for his employers past or present.

Paul: In tobacco-related circles you are perhaps best known for a 2003 document you were first author on while with ASH-UK, European Union Policy on Smokeless Tobacco, which essentially argued for modifying the ban on smokeless tobacco so as to provide a safer nicotine source than cigarettes for smokers. Now, ten years later, ASH seems to teeter between arguing for or against safer alternatives whether snus or e-cigarettes. At the time you were with ASH did you have support within the organization when you were developing that paper or were they just putting up with you?

Clive: The idea of ‘harm reduction’ is always controversial – whether it is needle exchanges for intravenous drug users, contraception for teenagers, or even cycle helmets. There are people who think that promoting anything other than quitting smoking completely is somehow an unacceptable compromise. But this takes no account of real human behaviour and that fact that what matters is what people actually do, not what you want them to do.

There was support within the organization because we argued the case properly and used the best evidence we had at the time, and it is even clearer now. You’ll notice that document is co-authored with some of the leading academics in this field and so the case has both weight of evidence and some authority. There were doubtless some in and around the public health field who were uncomfortable. But then, as now, they just could never make a convincing argument, so they had to put up with me and the others like me who see this issue more pragmatically. ASH remains pretty reasonable on all this if you listen carefully to what they say. The problem lies with the big health charities and European alliances, which just seem to take positions that appeal to their instincts and what they think will be popular.

Paul: There have been a few examples of people who started as active in anti-smoking or clean air initiatives but ended up promoting alternatives for smokers (for instance Michael Siegel, Bill Godshall or David Sweanor) but yours is the only case I know of where an active support of harm reduction originated from within an anti-smoking organization. When you started with ASH, were you already inclined toward harm reduction or did that position evolve over time?

Clive: I was fortunate enough to be the Director of ASH, and it is easier to influence the position of an organization if you are in charge! My views definitely evolved as I came to understand the underlying science better.

My first foray into this arena was looking into ‘low tar’ cigarettes, and whether they really were reducing health risks (nb. The answer is definitely ‘no’). That Low Tar report is still available and mixes science and some of the most tobacco industry documents to paint a picture of companies deliberately and cynically engineering false reassurance in response to the health concerns that were rising at the time. But the interesting underlying scientific premise is that smokers smoke to meet their nicotine needs (so-called nicotine titration) and adjust their behaviour to compensate for, say, vent holes in the filter, in a way that the official cigarette tar and nicotine testing machines do not.

I campaigned to have the tar and nicotine numbers removed from packs in the 2001 tobacco directive because they sent a misleading signal, but alas to no avail. The directive did at least clamp down on branding words like ‘mild’ and ‘low’ (article 7). But once you understand nicotine-seeking as the prime driver of smoking behaviour and that is the tar particles and hot gases in the smoke that are the main causes of disease, you are soon drawn into harm reduction and the idea of clean or cleaner ways of nicotine delivery. I had brilliant teachers on all of this in Martin Jarvis and Ann McNeill. They were part of a London-based group of scientists inspired by the work of the late, great Mike Russell, who pioneered the early understanding of the pharmacology and psychology of nicotine dependence.

Paul: Though one would think that for any group working with tobacco and health that promoting safer alternatives (such as snus or e-cigarettes) should be a logical step this just does not seem to happen. Is there something about the culture of these organizations that make change from within difficult?

I’m incredibly frustrated by some of the health groups. They’ve taken a cavalier attitude to the evidence and ethics of harm reduction, and seem to show no empathy or concern for the people they are supposedly trying to help. It is as if they value their anti-tobacco industry credentials more than doing something about cancer, lung and heart disease. If you swear a fight to the death with Big Tobacco, you will be treated kindly by politicians, the media, funders and the public. But if you care about health, and I mean really care, there are some tougher choices and trade-offs to make about reducing the harm caused by tobacco.

I also think there are some uneasy conflicts too: the European Commission provides funding to some of the Brussels based health lobbyists; Big Pharma is involved to some extent and has mixed motives; and some of the health charities have a funding and research philosophy that is ideological and narrow-minded rather than a genuine scientific quest. There is certainly a lot of group think and lack of internal critical challenge within these groups. Sad to say, I don’t think they even recognize that as a weakness.

Paul: In your most recent writing on tobacco, I see that you reiterate much of what you said ten years ago with the benefit of the evidence of the time since, but you restrict your comments to snus as an alternative. What are your feelings about e-cigarettes as alternatives and in comparison to snus.

Clive: I think the same arguments apply to e-cigarettes, vapour devices, NRT, non-combustible tobacco. They are all vastly less hazardous as a way of consuming nicotine and, unlike smoking, have negligible risks or risks that are not out of line with other lifestyle risks we routinely accept. Which do I prefer? Whichever works for each smoker.

My concern is not whether these alternatives are dangerous – they aren’t. My concern is whether they can quickly gain market share from cigarettes. The challenge from a health point of view is to get as many smokers, especially those over 40 years old and looking like they may be smoking for life, to switch. So I think we need a broad range of alternatives available to suit individual tastes and motivations.

This is an area where market forces could drive strong pro-health innovation as makers of these products seek to win market share from smoking. There will be an instinct to regulate, and in doing so to be excessively restrictive – but we must be so careful. Too much caution or excessive regulation of these alternatives would throttle the market and would in effect amount to protective regulation for the cigarette market. So my message to those health interests who want very strict regulation of new nicotine products is: “beware what you wish for, because if you get what you want, you will be doing the dirty work of the cigarette vendors for them”.

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