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.