New Ways of Thinking About an Old Problem
Walking into the majestic Royal Society building in London for the 5th E-Cigarette Summit, I was struck that the first painting of many great inventors visible in the vast rooms and stairways was that of Tim Berners-Lee, inventor of the World Wide Web. A new technology innovator, being honored in an old building. For me, attending the summit for the first time, and eager to listen and learn about the evolving science and policies related to e-cigarettes and other tobacco harm-reduction (THR) products, that painting set the stage for the content of the meeting. The well-developed field of tobacco control is now in transition. A focus on nicotine and novel products able to deliver nearly clean nicotine is challenging the strategies we have relied on since the 1970s to end smoking.
Over my career, I have been to many tobacco control meetings. They have a predictable format: smoking prevalence studies, classic epidemiology, the role and impact of regulations, the impact of tobacco industry interference on policy, the need for more money and leadership. The participants are also predictable. WHO and health officials, public health researchers, community activists and an occasional tobacco industry “spy.” This meeting was different in content and participants. The focus on THR was reflected in key questions addressed and in the participants.
Presentations by toxicologists and environmental exposure scientists discussed ways of assessing exposures to the chemical entities that can kill or cause disease in e-cigarettes and heat-not-burn products. Many studies by non-industry scientists repeated analyses done by tobacco and e-cigarette companies to assess their repeatability. (But not their validity. It was unclear whose gold standard is the best!) A range of biomarkers and early clinical measures of health outcomes potentially linked to THR products were presented. Critical analyses of studies of what many labelled as “bad science” highlighted common errors in misinterpreting or poorly designing studies on the impacts of THR products. These errors became amplified uncritically through uninformed media, leading to distorted public perception of the risks and benefits of THR products, relative to cigarettes.
The methods and comments by Dr. Jamie Hartmann-Boyce, from the Cochrane Tobacco Addiction Group on the evidence assessing whether e-cigarettes aid cessation, was framed in a pre-THR era in ways that were not fit for the purpose or addressed the actual use experience of e-cigarette users. Our hallowed belief that the best way to assess causality is through a randomized control study (RCT) misses the impossibility of assembling a group of participants who would get close to representing the THR user base of interest. THR products like e-cigarettes cannot be assessed through RCTs.
We need to develop better sub-experimental ways of assessing causality. The classic epidemiological approach to assessing if cigarettes kill (Ask people if they smoke, follow them ‘till they die or get sick, then analyze.) worked for 60 years but needs refining in the light of THR and the availability of new tools and insights. We need better measures of exposure, not so reliant on reporting alone, and better measures of outcome that predict future diseases and death without following large cohort studies for decades. Policy sessions at the conference were tightly focused on the probable impact of regulations on THR use and subsequently, on population health. The use of well described models showed the benefits of e-cigarettes in terms of millions of lives saved. Snus experts provided equally compelling data showing that hundreds of thousands fewer premature deaths from cancer would have been possible if European smokers had followed the Swedish example. This type of policy analysis merges more sophisticated modelling with well-considered assumptions in ways akin to how climate change researchers work. It allows decision makers and the public to understand the consequences of bad policies and inaction.
All presenters ended by identifying areas requiring more research, improved quality of research and multidisciplinary approaches. I was especially keen to hear these thoughts, which will be valuable to the Foundation as we develop our research agenda and determine areas where we can have the biggest impact.
But it was the diversity of participants that made for some of the best discussions and suggested to me how future meetings could make substantially more progress. Many THR users were in the audience and able to comment on the value of the work for them. This was a contrast to tobacco control meetings where smokers are not given “voice” or taken seriously. The mantra of the THR users, “nothing about us without us,” echoed the early call of AIDS activists for a seat at all tables where science and policies affecting them were discussed. As with the recommendations around research, this is a lesson for the Foundation to follow.
There were many tobacco and e-cigarette industry scientists in the audience but they remained mute as they politely listened to non-industry scientists review their work. The non-industry scientists started their talks listing possible conflicts of interest. None reported working for, or being paid by tobacco or e-cigarette companies, though many did report pharmaceutical links. The silence of the “conflicted” represents a missed opportunity for scientific progress especially since the level and quality of industry science probably exceeds that of all but a few public health researchers. And it seems contradictory to the clear statement of the lead Department of Health representative in response to questions about whose science government uses. He said that “England follows the (US) FDA lead, and relies on the quality and methods of the research in deciding what to use, and not on its source.” That being the case, future meetings need to open scientific debate to all who are qualified and able to meaningfully engage.
The dynamism of the presentations was matched by the presence of groups I had never encountered before. Tim Phillips, managing director of E-Cig Intelligence provided new data on trends in the field. The International Network of Nicotine Consumer Organisations reports membership across 20-30 countries, and the International Symposium on Nicotine Technologies (held just prior to the E-Cigarette Summit) is driving levels of innovation that will go well beyond current THR products. The Foundation will support such innovation, extend it into cessation products and ensure that innovation benefits the poorest countries.
The last keynote was by Sarah Jakes, a board member at the New Nicotine Alliance. She challenged the very notion that all smokers want to quit. She reminded us “non-users” that she and millions of THR users seek pleasure – ideally associated with the lowest possible risk. We would do well to understand how this insight could help speed up development and adoption of products that will save the lives of millions of smokers.