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  • Sally: We're here with Clive Bates, one of my most esteemed colleagues in the world of

  • e-cigarettes and vaping, and more largely, public health.

  • He is an expert in tobacco control, has worked for many years in that.

  • For a number of years, he was the head of Action on Smoking and Health, which is a public

  • health advocacy group based in London.

  • And since then, he runs this magnificent blog called The Counterfactual, and his analytics...your

  • analytic skills are just...and your knowledge...the scope of your knowledge is really amazing,

  • and you're a wonderful writer as well, so I'm so thrilled to have you here.

  • Clive: Is the whole interview gonna be like this?

  • Sally: It could be.

  • So let's talk about e-cigarettes, vaping, tobacco harm reduction.

  • Frankly, how exciting it is and the difficult time it's having in this country in becoming

  • more widespread.

  • Clive: Yeah.

  • I'm in the world of tobacco.

  • There's just been the most amazing developments in the last few years.

  • I mean, we have ongoing, essentially, a technology-based disruption of what is a huge and stable entrenched

  • industry.

  • So the tobacco industry is about $800 billion worldwide.

  • So it's a huge industry selling about six trillion cigarettes to around just about 1.3

  • billion smokers, okay?

  • Massively profitable, and its profitability has been rising over the last decade.

  • You know, people in our business, tobacco control, often think we're winning, but if

  • you measure it by the profitability of the companies, we're definitely not winning.

  • So along comes a new technology.

  • Essentially, developments in batteries mean that you can now heat a liquid, create a vapor

  • aerosol, it will deliver nicotine to the lungs in a way that many smokers find satisfactory

  • without all the stuff that goes with setting fire to tobacco leaf and inhaling it.

  • And it's that products of combustion of organic leaves that do all the damage associated with

  • smoking.

  • So the experts in the UK have assessed the evidence, and they would say that e-cigarettes,

  • vapor products, are likely to be at least 95% less risky than smoking, and probably

  • a lot lower than that even, just based on the toxicology of what's in the vapor.

  • And in that understanding, that is the most amazing potential for a public health breakthrough

  • in the United States, in Europe, and worldwide.

  • Sally: Right.

  • Actually, this is something we can come back to, but it's so fascinating how your country

  • is so progressive on this product, which is referred to as...the FDA, by electronic nicotine

  • delivery...

  • Clive: Delivery systems.

  • Sally: ...systems.

  • ENDS.

  • Also known as vaping, e-cigarettes, and which are now in their third and fourth generation

  • of devices, let's say, can deliver nicotine more efficiently, but still not as good as

  • the actual product.

  • Clive: I think we got off to...we didn't get off to the greatest start in the UK.

  • The instinct was to use a illness treatment cure model.

  • You know, smoking's the illness.

  • You need a treatment like a drug or a nicotine replacement therapy and then you will be cured.

  • And what they did was conceive of these things as a treatment, like nicotine replacement

  • therapy, or Chantix, or one of those medical things, in which the medical profession intervenes

  • to give a smoker a medical thing that cures them of smoking.

  • Of course, that's not what it is.

  • Most of the smokers who are switching to vaping don't see it in that way at all.

  • They don't classify themselves as patients.

  • They don't think they're taking a medicine, and they don't go to treatment settings to

  • get it.

  • Sally: They're true consumers.

  • Clive: They're making a consumer choice, so it's a little bit like somebody who decides

  • they're gonna get a bit fat and they're gonna switch from full sugar Coke to Diet Coke or

  • something like that.

  • And they're making a consumer choice that has a collateral health benefit, and that's

  • one of the reasons why they are doing it.

  • And it's all going on in the marketplace.

  • Medical professionals are not really involved or haven't been that much.

  • Many of them have set themselves against it, in fact.

  • There's no public spending involved.

  • Taxpayers are not harmed.

  • No one has asked the public health community for their permission to do this.

  • These products have emerged from innovators on the market.

  • Consumers have voluntarily started to use them and become experts in them.

  • Sally: Right.

  • Why are they so attracted to them?

  • What are the virtues that they say?

  • Clive: It's fascinating because I think what they do is they replicate the value that smokers

  • find in smoking, which is a number of things.

  • It's several things at once.

  • It's a delivery of nicotine in a way that provides a meaningful physiological effect,

  • you know, a buzz.

  • It replicates some of the throat effects.

  • It provides taste.

  • It provides warmth.

  • It provides something to have in the hands, behavioral ritual, something that fills rituals

  • that happen at certain times of day, you know, having the coffee and morning croissant or reading

  • the newspaper, that kind of thing.

  • So it drops into the same place in life that cigarettes are, but it doesn't have all the

  • disadvantages, like, you know, cancer, heart disease, respiratory illness.

  • That's not to say it's completely safe, but nevertheless, those things are taken out probably

  • quite a bit cheaper as well as a habit to pursue.

  • Then it has a whole load of other things, sort of there for the geekiness.

  • You know, people like the technology.

  • It's high degree of personalization involved, so people can configure the devices and the

  • liquids that they use to exactly what they want, and they can change those according

  • to their mood, the time of day.

  • They can progress through different types of products over time.

  • So what it does, it sets up an alternative value proposition to smoking that many smokers

  • find attractive, even if it's not a complete substitute.

  • Taking everything into account, it works out a better deal for them and they go with it.

  • Sally: So I'm going to pose to you the kinds of objections that at least our public health

  • community, not everyone, I mean, there are some folks who are responsive to data, but

  • there is a lot of ideology driving the resistance, and I'm gonna name the four basic arguments

  • against it.

  • One is that it normalizes smoking.

  • A lot of this concern surrounds the children.

  • It normalizes smoking, it will be a gateway to smoking.

  • Dual use, in other words, continuing to smoke while you vape is not a good idea, and nicotine

  • is dangerous.

  • Clive: Okay.

  • Okay, so renormalizing smoking, it's never been that obvious to me why the emergence

  • of an alternative technology to smoking somehow normalizes smoking.

  • Surely, what it does is normalize the alternative behavior, which is giving up smoking by switching

  • to vaping.

  • No one does ever provide any compelling evidence that this is actually this bizarre thing.

  • When you think about it, it's a bizarre claim that you launch a new product and actually

  • what it does is increase sales and use of the old product.

  • It doesn't do that.

  • It does exactly the opposite, and there's no evidence to support it.

  • It's just a made-up argument that has no basis in reality, and to be honest, it doesn't really

  • have any basis in plausibility.

  • Adverts for e-cigarettes, marketing of e-cigarettes market e-cigarettes.

  • They market an alternative.

  • Sally: Gateway?

  • Clive: Gateway effect.

  • First of all, there are the people who talk about the gateway effect.

  • When you actually say, "Well, what exactly do you mean by a gateway effect?"

  • What you'll get is some slightly confused or very confused, often, things about, "Well,

  • they started on e-cigarettes and then they went to cigarettes, okay?

  • And that means the e-cigarettes were a gateway."

  • It doesn't mean that at all.

  • To understand whether there was a gateway, what you have to do is imagine a world without

  • e-cigarettes and look at all patterns of smoking there would be.

  • So some people never smoke, some people would smoke.

  • And then you introduce e-cigarettes into that world and those pathways all change.

  • So some people who smoke would switch to e-cigarettes and then maybe quit completely, and that's

  • a gateway exit.

  • That's a good gateway.

  • Those are the gateways we want.

  • So then you have to find...to find a really harmful gateway, you have to find someone

  • who would never have smoked, and bare in mind, it's hard to know that.

  • They have to then switch to e-cigarettes, which does them a bit of harm that they wouldn't

  • have done to themselves otherwise.

  • And then they have to move on and graduate to the big harm, which is smoking.

  • So finding people that have gone down that pathway is extremely difficult.

  • No one can really produce the people that have done that.

  • None of the studies really do show that, and none of them are set up to do that kind of

  • follow-up work or to measure people as they progress through these things.

  • So what happens is that people overclaim on gateway effects.

  • They find associations between vaping and smoking and then they conclude that the vaping

  • is causing the smoking.

  • What is much more likely, though, is that the same things that incline people to smoke

  • are the same things that incline them to vape.

  • In other words, there are same personality characteristics that cause the two things

  • to happen.

  • And if they take up vaping and they would have otherwise smoked, it's a benefit to them.

  • So I don't think there's anything in the gateway effect, and when the Royal College of Physicians

  • look to this, and Public Health England, they said, "First of all, the concept's so woolily

  • defined, it shouldn't even be used."

  • And certainly, there's no evidence to suggest that's happening on a meaningful scale.

  • Sally: Yeah, and the epidemiology certainly bears that out in that there are fewer and

  • fewer teens who are smoking.

  • So if there were...

  • That's the big story.

  • If there was a gateway effect, where are all the people who are emerging the other side

  • of the gate?

  • Sally: Right, exactly.

  • Clive: You know, they're not there.

  • In fact, teenage smoking is falling to the lowest levels and at the fastest rate in history,

  • coinciding with the rise of vaping.

  • So it suggests that if there's a gateway, it's an exit, not an entry to smoking.

  • The other one was dual use.

  • Clive: Okay.

  • So dual use, it's odd that people think that dual use is a bad thing.

  • If somebody starts using a different product instead of smoking, there are a number of

  • good things that could come out of that.

  • First of all, if they carry on, then their risk is likely to be reduced.

  • Some of the health effects of smoking are proportional to exposure.

  • And therefore, if you reduce your exposure...

  • Sally: You have the respiratory effects.

  • Clive: Yeah, exactly.

  • And actually, cancer effects as well.

  • Sally: But the cardiovascular, we're not so sure.

  • Clive: Cardiovascular, there's some doubt about where there's non-linear effects and

  • so on, so there may not such a benefit there.

  • But hell, respiratory cancer, that's something.

  • Sally: That's huge.

  • Clive: Then it's the argument that actually many...you have to look at this dynamically.

  • So if you just take a snapshot, you may be missing the fact that people are on a lengthy

  • transition.

  • They're going from being 100% smokers and they're gradually shifting through dual use

  • to not smoking at all, or smoking on an occasional basis.

  • And then the final thing I think to say about dual use is it's not one thing.

  • You know, somebody who vapes all the time and then smokes a bit at the weekend when

  • they've had a few drinks, they're not at particular risk.

  • Occasional smoking isn't a big deal.

  • It's daily smoking that you need to worry about.

  • And of course, they are very different to somebody who smokes all the time and vapes

  • every now when, you know, they're not allowed to smoke.

  • So those are two people who would both be classified as dual users, but their pattern

  • of use is completely different, that it's meaningless to lump them together in a single

  • category.

  • So you need to dive into the data to understand what's going with dual use, but it's definitely

  • not a bad thing.

  • It's only goodness comes from dual use, no badness.

  • Sally: Nicotine?

  • Clive: Well, nicotine has been studied extensively for many, many years in a way in which it's

  • consumed separate to smoking.

  • So nicotine replacement therapy patches and gums and smokeless tobacco, Snus, for example.

  • It's pretty clear that nicotine is not the harmful agent.

  • It's not completely benign, but then caffeine isn't completely benign either.

  • Nicotine does have some effects on the body, so, you know, it changes pulse rate.

  • It has effects on the cardiovascular system.

  • And what people have been doing is they'd been measuring those effects and going, "Oh,

  • look, something bad is happening."

  • But actually, that's normal.

  • Those bad things happen when people take caffeine, when people go running, when people listen

  • to rock music.

  • You see physiological responses to these things, but they don't necessarily lead to people

  • keeling over dead with heart attacks and strokes in the future.

  • Sally: And they tend not...in many of these studies that look at the effects of vaping,

  • they don't compare them to cigarettes because the whole keyword here is "relative."

  • Clive: Well, the Surgeon General did a very exhaustive review of the health effects of

  • smoking, and the conclusion of that was that the things that cause cardiovascular disease

  • in nicotine is the products of combustion like carbon monoxide, oxides of nitrogen.

  • They're just not present in e-cigarettes because there's no combustion.

  • So I think they're trying to argue that nicotine is a harmful agent because it's integral to

  • the product.

  • You obviously can't take it out or it's no longer a substitute, but we've never heard

  • in the past about passive nicotine exposure.

  • We've never really had the emphasis on nicotine as the harmful agent until now.

  • And the truth is it's not completely benign.

  • There may be issues for pregnant women or for teenagers, but in all circumstances, it's

  • better to take nicotine from an e-cigarette than nicotine from a cigarette.

  • Absolutely no question.

  • Whether you're pregnant, whether you're four years old.

  • That