No smoker left behind

Working on a shoestring, the New Nicotine Alliance is encouraging smokers to switch to less risky products—while desperately trying to prevent others from botching the opportunity.
By George Gay
I know it’s not the done thing to mix editorial and commercial activities, but I want to start this piece with an appeal for money—though not on my own behalf for once. If you have some cash to spare, perhaps you’d like to donate it to charity—to the New Nicotine Alliance (UK).
Given that tobacco smoking is such a breathtakingly serious cause of disease and death, there could be few more-deserving causes than one devoted, as the New Nicotine Alliance (NNA) is, to encouraging combustible cigarette smokers to switch to less-risky products. And yet I happen to know that the NNA is financially impoverished. It is trying to communicate what must be one of the most important public health messages of all without having a budget to do so. How ridiculous is it that an organization with such aims should be starved of cash?
Even stranger, perhaps, is that despite such an obstacle, it manages to get its message across rather well: For instance, by providing a point of reference for health bodies focused on tobacco harm reduction; by providing a reliable source for journalists wanting to write about less-risky tobacco and nicotine products; by having a presence at any number of nicotine-focused exhibitions and conferences; by presenting evidence to parliamentary groups; and by appearing in court in support of its goals.
In no small part, this success is down to Sarah Jakes, the organization’s chair. Jakes is quietly assertive, as is often the case with people on top of their subject. But don’t be fooled, she can be feisty, famously telling a U.K. E-cigarette Summit held at London’s Royal Society in 2017 that the people involved in the rowdy e-cigarette revolution were trying to stop others from “fucking it all up.”
Speaking with Jakes during a meeting in London in May, it wasn’t difficult to understand the cause of such frustration. Contrary to what some people say, Jakes thinks there are lower-risk products available that could help just about every cigarette smoker switch from combustible cigarettes; and yet, the U.K., where the official line generally favors tobacco harm reduction policies, is suffering a hiatus in people switching from smoking to vaping.
Distortion
Without knowing some of the background, it is almost impossible to understand why this situation has arisen. Take electronic cigarettes. Not only do they clearly offer a huge health advantage, they also offer a massive financial saving, in part because they are not subject to excise tax. In fact, Jakes told me that she vapes for £0.40 ($0.54) a day whereas her former smoking habit would now cost her about £9.00 a day. Okay, there are several factors that could mean that Jakes, who mixes her own e-liquids, is able to vape for a lower cost than some other people who buy ready-mixed liquids, but even so, this price message should be one that is being shouted from the rooftops. Indeed, the government should seriously consider handing out devices to financially impoverished smokers, given that a decent starter kit can be bought for about £25.
Jakes believes that the hiatus in switching has partly to do with the early adopters of vaping having already switched, but she says too that it is about distorted, adverse media stories. You can see her point. If a smoker’s primary reason for switching is to reduce risk, and she frequently reads in her newspaper that vaping is going to give her cancer, the incentive is removed. The incentive is removed too by public places bans, and, while there is no regulatory prohibition on vaping in public places in the U.K., vaping is banned in more places than it is allowed, partly because venue owners and transport providers find it easier to lump vaping with smoking than to come up with specific vaping policies. Another disincentive is provided by adverse media stories and public places bans coming together with other factors to heap the grossly unfair stigmatization smokers are subjected to onto vapers as well.
Part of the reason for the adverse media stories lies with “junk science,” which is something that clearly rankles Jakes. When I suggested that perhaps such “science” was the result of incompetence rather than malicious intent, she politely called my observation “generous.” Apparently, a vast amount of the money that has been made available to researchers is used to look at the “issues” surrounding vaping and not its benefits—and it seems that the amount of funding you receive is in direct relation to the adverse findings you publish. This means researchers are coming to conclusions that are not supported by their results, and those conclusions are exaggerated in press releases that the media is happy to turn into lurid headlines. Many of the stories about vaping simply weren’t true, said Jakes. There was no way to dress them up. They were based on lies.
Funding
The NNA, which was formed in 2015 as a U.K. registered charity, relies heavily on the public health knowledge and organizational skills of Professor Gerry Stimson and Paddy Costall, two of the original and current trustees, but it is a consumer-led organization—and one that has found a niche. Jakes, who is also one of the original trustees, told me that the NNA had opened doors almost immediately after it was set up because it had given regulators and public health professionals a point of contact with consumers, and a point of contact that, because of its charitable status, was transparent and subject to oversight. There had been a desire within various organizations, and especially within Public Health England (PHE), to engage with consumers, and the NNA provided a path that they could comfortably tread, in part because the NNA did not take funding from any industry.
As is mentioned above, the downside of this is that the NNA is financially impoverished. Last year, about half its funding came from a contract to advise on PHE-funded films produced by the National Centre for Smoking Cessation and Training. The rest came from activities such as fundraising at exhibitions, a raffle organized by Vape Jam and individual private donations.
Funding problems are eased by the Internet, without which the NNA, and, arguably, the vaping industry, probably wouldn’t exist. The Internet—social media and online publications—is the place where vapers carry on their rowdy revolution. It is where vapers communicate; where they learn about new, alternative products; where they learn how to use those products; and where they get across calls for advocacy. Importantly, too, it is where smokers can listen to what is going on and perhaps join the revolution.
Of course, the Internet is also something of a distorting lens. It contains so much information that it is easy to forget these are still early days for vaping. Jakes reminded me that vaping has been around for only 10 years, though for those involved in advocacy that seems like a lifetime. “The landscape of tobacco harm reduction is still forming,” she said. “What we have at the moment are groups with different objectives and priorities; so we don’t see a unified voice yet. But we are getting there. We all have the same core aim, and that is to reduce the harm caused by smoking.”
One crack that appears in the harm reduction landscape has to do with the medicalization of cessation, which is a barrier to a lot of smokers who don’t see themselves as ill or patients. And there is a tendency for the cessation debate to focus on whether products are efficacious in getting people to quit smoking, while Jakes points out that it is important to look also at the recreational aspects of vaping and the pleasure it can deliver, along with harm reduction.
The NNA has one part-time paid administrator, but the rest of its people are volunteers: mainly vapers and people with a range of experience in activities such as stop smoking services. It’s not easy. Volunteers must be willing to give up their time and the activities can be time-consuming. Jakes reckons that she spends about two working days a week on NNA business, something she can do only because she runs her own business.
It’s not easy, but it seems to work, and the proof of concept can be seen in the fact that there is now an NNA (Australia) and an NNA (Sweden). Because the NNA had become prominent in the U.K. it was decided to allow people to fly the NNA banner in other countries. The offshoots, of which there will probably be more soon, operate autonomously but use the NNA name subject to certain conditions.
Mainly, the NNA is U.K. focused, but it does get involved in wider issues. It supports organizations in other countries if they ask for help; for instance, after a request from vapers, it submitted a response to a consultation in Iceland that was discussing laws that were like those of the EU’s revised Tobacco Products Directive (TPD). And it gets involved on an international level if, for instance, the World Health Organization (WHO) is, in Jakes words, “up to something.”
Junk science
Both the TPD and the WHO could, I imagine, bring out the feisty side of Jakes. I asked her if she had noticed any movement in the WHO position on vaping following the appointment last year of a new head of that organization. On this occasion, she didn’t describe my position as generous; she simply said, “no, and I fully expect them to get worse.” All the evidence the WHO seemed to take notice of was cherry-picked junk science, mainly coming out of California, Jakes said, and it seemed to pay no mind to the section in the Framework Convention on Tobacco Control (FCTC) that provided for governments to take a harm-reduction stance in relation to tobacco. The WHO basically supported bans and seemed unlikely to change its position.
Meanwhile, the TPD is particularly unpopular because it brought in a raft of arbitrary e-cigarette restrictions that were not based on evidence, that were not the subject of any impact assessment, and that, consequently, just made the life of vapers more difficult. The TPD restricts e-liquid tank sizes to 2 mL, refill bottle sizes to 10 mL, and nicotine strengths to 20 mg/mL. All of those are counterproductive. The 2 mL tank size is simply an inconvenience, but, because it is so small, the 10 mL refill bottle, as well as being an inconvenience, a hazard for people with conditions such as arthritis and an obstacle to those wanting to read what is on the label, is wasteful in respect to e-liquids and waste creating in terms of single-use plastics. The 20 mg/mL strength restriction is particularly damaging for heavy smokers who need higher nicotine strengths to get them off smoking initially.
The TPD is unhelpful, too, because of the advertising restrictions it imposes. In the U.K., these restrictions lead to what would be a laughable situation if it weren’t so serious. Jakes says that while PHE is falling over itself to get the message across that vaping is safer than smoking, those that would disseminate this message for nothing—the vaping product suppliers—are not allowed to do so.
Keep trying
I couldn’t resist asking the $6 million question. Did Jakes think that the NNA could prevent others from “fucking up” the rowdy revolution. After all, the list of people involved, I said, took in smokers, vapers, cigarette manufacturers, vapor product suppliers, pharmaceutical companies, scientists, the media, pro-choice advocates, tobacco control people (of all hues), politicians, treasury officials and regulators. Probably not, was Jakes reply, but she vowed to keep trying. All the people listed were interlinked and all had a part to play. But as things stood, so much policy, such as that in the TPD, was based on ignorance. The voices of the experts in this field—the consumers—have to be heard. They are the people who know what the unintended consequences of policies would be.
One additional problem is that there are differences of opinion within these groups, though the pharmaceutical industry takes a generally united line, supporting only nicotine-replacement therapy products. Even within the ranks of consumers, cracks appear. There are smokers who see vaping as a threat to their right to smoke. And there are vapers and vapor product suppliers who see heat-not-burn (HnB) products as a tobacco industry Trojan Horse.
Jakes takes the view that HnB products should be supported because they add to the harm-reduction avenues that are open to smokers. “I don’t want anybody to be left behind,” she said. “I want there to be an option that is attractive to everyone.”
While Jakes doesn’t want anybody left behind, she tends not to leave any product behind. She carries an array of reduced-harm products that she can use as the situation demands. And situations tend to be unpredictable for vapers who head overseas. Airline rules, sometimes arbitrarily applied, and laws in other countries can cause problems and it is best to be well prepared. As we were speaking, Jakes was using a Zyn tobacco-free, 6 mg nicotine oral pouch product that had been bought in the U.S. Zyn stands testament to the ignorance that can underpin policy and bureaucracy. Apparently, Zyn, the consumption of which must be six zillion times less risky than smoking, cannot be sold in the U.K. because there is no “route to market for it.” And it is not the only reduced-risk product to have hit this wall, which must have been built by descendants of Josef K’s tormentors.
I don’t want to go into too much detail about which products are in favor and which are not because, frankly, it feels like a descent into madness. But it is interesting—if worrying—to note that the EU seems to favor products that are the most addictive, such as combustible cigarettes. It doesn’t seem to like electronic cigarettes, for which there is evidence to suggest that addiction is not an issue or is far less of an issue. Vapers tend to reduce their level of vaping, partly as they get more skilled at the habit and partly because of the better performance of newer products, and some change their habit to the point where they no longer use nicotine. Additionally, some vapers who are ex-smokers report that even if they lapse to smoking, they have little trouble going back to vaping exclusively.
This seems to raise the question as to whether the issue of nonsmokers taking up vaping should be of concern. Well, according to Jakes, it should be of concern only if it leads to harm. “I think you would be burying your head in the sand if you said that no nonsmoker would ever take up vaping,” she said. “However, most people worry that vaping might lead to smoking, but there is no evidence of a gateway effect.”
And it could be that vaping diverts people who would otherwise smoke to something that is very much safer. “I think we must be careful about attracting never-smokers into vaping because they tend to be young people who probably aren’t old enough to make a decision that could affect them for a considerable period of their lives,” Jakes added. “We need to be responsible about that, but we don’t need to panic about it.”
That sounds like advice that, in large, friendly letters, could be a guide to the vaping galaxy.