And Now We See Through a Glass, Darkly pt 1

My very first guest blog! Quite excited actually. This is linked to my blog so to get a full picture of the situation that arose to prompt this I'd read both. Consider this 1 of 2 or 2 of 2 depending which way round you read them.

This is from Sarah Jakes (@twigolet) who is a fellow vaper and member of the board of NNA. Both my blog and this one are NOT opinions of NNA they are ours as individuals.

I want to say this before I move on to write my own post about the NHS and e-cigs. Sarah and I have come at this from different angles and what really struck me when I read this in the email she sent me was how uncomfortable it is to acknowledge the point she is making, but she is so right and I hope a lot of people (especially those involved in tobacco control in any form) read this and see one of the realities laid bare.

I have to say Thank You to Sarah, I was really upset today at the accusations and this email and her support meant a lot. Thank you also for the messages I got from other vapers - I really appreciate it!

So read on folks. Read on.

Ecigs, NNA and the NHS

Last night one particular aspect of a blog written by James Dunsworth on the Ashtray blog http://www.ecigarettedirect.co.uk/ashtray-blog/2015/09/public-health-u-turn-on-e-cigs.html sparked what was, to me, a rather odd response on Twitter. The blog was a summary of events at an APPG meeting in Westminster on Wednesday which NNA attended, and the comment was this:

Lorien [trustee] of the New Nicotine Alliance believes that if the NHS supply e-cigs it would reassure smokers that e-cigs are safer than tobacco cigarettes.

She also pointed out that a decent e-cig kit would set some smokers back a week’s worth of tobacco. Coupled with a worry about whether e-cigs are safe or not that would stop a lot of smokers from trying them. If e-cigs were supplied on the NHS, smokers could take the risk of using them without losing a week’s worth of tobacco.

The discussion at the meeting surrounding the provision of ecigs on prescription was provoked by the media coverage surrounding the recent Public Health England report most of which focussed on that issue. It was widely accepted at the meeting that this was an irritating distraction from the main thrust of the report, which was to correct public misconceptions about the relative harms of ecigs when compared to smoking. However, NNA does not control the agenda at APPG meetings, parliamentarians do, and so the matter was raised and discussed.

The comments on Twitter were strongly suggestive that NNA is actively supporting and promoting the notion that ecigs should be regulated as medicines. In fact what was actually said was “Lorien’s NNA statement sells our consumer choice to statist f*cknuts. Which is why I don’t trust NNA”. How anyone could come to that conclusion without having consumed a large amount of some sort of paranoia inducing substance baffles me. In fact, I find it utterly insulting given the large amount of our own time and energy which Lorien and the other trustees, including myself, have given up in order to fight this battle. The fact that the UK has one of the most progressive policies in the world with regards to e-cigarettes is very far from solely down to us, but we’ve certainly played our part alongside a great number of other organisations and individuals.

NNA has no official position on whether or not ecigs should be provided on the NHS. A common argument for provision by prescription is that smoking prevalence is highest in poorer groups of people who may not wish to take the financial risk of purchasing an ecig and prescription will assist with this barrier. My own view is that that is an over simplification and I explained my thoughts in a recent email:

Whenever I hear the socioeconomic arguments about smoking behaviour / cessation and ecigs I wonder why no one ever seems to ask themselves why people in the lower groups show higher dependence and failure to quit. If their quit attempt rate is the same then I guess you can say that as many of them want to quit as do in other groups, so what is it about being poorer that makes that more difficult? 

I don't think it's as simple as offering them free stuff although that might help. But a decent starter kit can now be bought for the price of 3 packs of hooky fags, so what is making the difference? I think it's something that runs much deeper. When people quit I think that's because they're looking to the future in terms of health and wellbeing, and maybe that's something people do less of if they have little in the way of prospects. They see the health warnings, think they probably should quit but don't really have as much incentive to stick at it as more affluent people do? 

For many people smoking could be one of their only luxuries, and it's a social thing which people share - it could be that it means a lot more to people in those groups than it does to those with more alternatives. If so then the lost enjoyment cost of giving up smoking could outweigh the perceived benefits, or at least be much more finely balanced than in other groups. The 'health inequality' arguments are then futile because the balance people seek is about much more than just health and finances. Medical and scientific thinking seem to very often forget about the 'people factor'.

Lorien however, quite rightly points out that for some groups of smokers free or low cost ecigs could be beneficial. Let’s be clear here, we’re not talking about a lifetime supply and we’re not suggesting offering them to people who already vape. What we are talking about is enabling the NHS to offer people a device which could start them on the road to switching to vaping – people who would not otherwise try, perhaps because they don’t want to risk spending their cigarette money on a product which will not replace them, or perhaps because they are not confident about the relative safety of ecigs. In either case the NHS can offer confidence and support for those who lack it and perhaps for some a cost effective financial (for the state) solution for those who won’t take the initial risk. 

Whilst I have my doubts about the efficacy of any medicinally regulated ecig (if one were ever to exist) I believe the lives and health of all smokers are important, and so I think we have to try.

The above has absolutely no bearing on NNAs support and advocacy for ecigs as a consumer product. We are firm believers that an important benefit of the current market is the fact that consumers choose to use ecigs as a safer alternative to smoking. They work precisely because they are not medicinal and because they empower people to take control of their own health and lifestyle. This is a point which NNA makes frequently to legislators, regulators and practitioners alike. However, ecigs don’t work for everyone who wants to stop smoking, and so if Lorien is right and NHS prescription could help a further group of people then that is what a caring state should try to do. Consumer regulation and medicinal regulation are not mutually exclusive ideas and I’ve seen absolutely no indication of any intent to use the latter to the detriment of the former – in fact quite the opposite – what I see is a political will to make both markets succeed. Tin foil hatters may have differing views but I’m afraid we’ll just have to agree to disagree. Sorry about that.

And Now We See Through a Glass, Darkly pt 2

E-cigs and the NHS. Prescriptions. A medical e-cig.

All things guaranteed to get the blood boiling in people of both sides of the fence and even those sat atop it. This has been playing on my mind for a while and I probably would not have gotten round to writing about it had things not taken a peculiar and rather nasty turn last night.

Fortunately, I only found out about it this morning which is a good thing cos I was on something like 60 hours wakefulness with a mere one hours sleep and I doubt I could have strung anything more than the very worst insults and swearwords I could think of. And, well, that just is not becoming for a lady and anyone who knows me will attest to how fickle I am about being a lady.

Moving on.

It should be fairly clear to anyone that has followed this for any length of time that vapers are not fans of the medical ecig idea, and this is for a myriad of reasons. The stigma of NRT & medicines, the restrictions it would bring about, the financial burden of obtaining the licence that would put pay to our rather lovely and exciting e-cig market that smokers are flocking to.

But. In the UK we are somewhat fortunate, or at least more fortunate than many of our European counterparts. We will have a dual market - a consumer market and a medicinal market. At present there are no medicinal e-cigs. In fact there aren't even any ABOUT to be medicinal e-cigs. There is a misconception that BATs Voke is an ecig, it is not. It is little more than a glorified inhaler that looks like a cigarette.

I am not about to enter into a debate in this blog about what the TPD is going to do - that is not the point of this and I do have some MAJOR concerns about a medicinal ecig, the main one being if those in mental health settings were restricted to only being able to use them. For me that is such a massive point it is almost insurmountable, however, as one of my psychotherapists once told me, you have to imagine a situation as a bubble in your hand so that you can turn it and look at it from all different angles. 

So, this is about the fact that I was roundly slaughtered by someone on Twitter for comments they thought I made in the APPG on E-cigarettes in parliament yesterday, so let me take the time to explain what I meant for those who appear to have forgotten everything I have said before.

Firstly - I do not support a medicinalised e-cig market. I do not think that a med e-cig will be fun, appealing or even particularly effective. Despite what the public now thinks (thanks to some frankly insane headlines after the release of the PHE statement) we are not about to nor are we EVER going to see even a basic ego (second generation ) via the NHS, let alone a variable wattage or temperature control device. Whatever comes via that channel is highly unlikely to be anything anyone would want to use for any length of time when they have a world of options in the consumer market. 

So what does it mean if one day, a device (likely to be a cigalike or similar) appears as a medical product? Who would even want it?

Who indeed.

It is very important that you read the other part to this blog written by Sarah Jakes - it highlights why this is just one of a great many aspect of smoking and vaping and peoples relationships with both habits. Especially the former which we are now truly learning is far more complex than anyone dared to talk about openly.

My point at the APPG was in response to the 'Why should the NHS pay for smokers to have an ecig? If they can afford to smoke, they can afford to vape!'.

In many respects, I actually agree with this except in one. It is widely accepted that those smokers who would fall into the lowest socio-economical groups are most likely to be using illicit tobacco. In fact, a survey from ASH in 2011 suggests that 53% of smokers in group DE use illicit tobacco (thank you for the link DP). What does that mean? It means 'Working Class' and 'Casual or lowest grade workers, pensioners, and others who depend on the welfare state for their income' according to Wikipedia. For the record - I hate those phrases with a passion. 

The prices these groups are paying for that tobacco are probably half that of what it costs to buy over the counter. I would give a precise amount but there isn't a site called 'How little can I buy tobacco for?' so I have to rely on vague tobacco control literature. We DO know that £20 will set you up with an entry level second generation e-cigarette that will be the perfect starting point for any smoker who wants to try it out.

But what has happened in the past two years? We have been bombarded with scare stories and fear-mongering. If the e-cig isn't going to blow up in your face, then it is going to jump out of your pocket and poison everyone within a mile radius! If either of those two things don't happen then it is going to fill you so full of formaldehyde that Damian Hirst is going to be banging on your door demanding to split you in two and hang you in a perspex box! And if THAT doesn't happen well it won't help you quit or change habits cos they just don't work - and anyway, they are more dangerous than cigarettes don't you know with all those ultrafine particles burning holes through the lining of yours lungs! Assuming, of course, they can get through the layers of oil that are causing lipoid pneumonia or that your lungs haven't leapt out of your MRSA riddled body and run down the road smelling slightly of popcorn. Not that you'll be running anywhere cos that vapour restricts the ability to breath and that mouth and throat cancer you are going to get are DEFINITELY going to stop you even walking up the stairs!

In fact, they are SO (possibly maybe we don't know yet) dangerous that not ONLY must they be banned like cigarettes but we can't see or smell or even get a suggestion of marketing and by golly it is best that they are taxed immediately! 

AND AND AND they will give your computer a VIRUS!!

Actually - LET'S JUST PANIC!!!!

I know it sounds all rather absurd, but remove all your knowledge and all the ins and outs that we know about. Ignore all the studies you have read, the programmes you have watched and experts you have listened to. We are not representative. Remove ALL that you know and the above is all you have been told. The media, the telly friendly experts, the BMA, the WHO, the CDC and the list goes on. They have all told you not to use e-cigarettes.

So why on EARTH would you say to yourself,

'Well, I have a weeks worth of cig money here, do I blow it on an ecig that might melt my face or turn my kids into cocaine snorting animals and probably won't work anyway? Or do I just buy some cigs and try it another time.'

I think we all know what the answer is likely to be. So where does a medical e-cig fit into this? What would it do for someone in this position?

If they chose to, they could go to their Dr, get a (probably crappy) e-cig and suddenly you have proof of concept. They get the chance to say 'Oh wow this is utter pants but tell you what, I bet the ones they sell at the garage are better than this! Have you seen all the different flavours? Sod it, I'll try one!'

This ONLY works if there is a vibrant and exciting e-cig market for them to turn to, and turn to with confidence. The draw of being self sufficient and not reliant on the state for smoking support is one of the reasons vaping has taken off so quickly but that initial jump is still too much if you are risking a week or two with no tobacco at all if your purchase turns out to be all the things the media told you it would be. Why would you take that risk?

What this comes down to is choice. We fight for our right to choose but at the same time we abhor the idea of a medical e-cig. What if that is the only choice a smoker has? What if their choice is to take the support of the system cos that is what they want? It might only be a fraction of smokers but that fraction DO want structured state support. It is their choice to take it and use it. 

How can we talk about choice if we are deciding for them that they can't have that? What right do WE have to to take that decision for them? Do we get to dictate the grounds on which smokers choose their path to vaping? How is that the freedom to choose?

In the UK a med e-cig will not affect the consumer market at all. However, the consumer market does provide a bright and appealing option to the smoker that tries the med ecig and realises there is so much more to be had.

We run the risk of getting caught up in the anti-smoker mentality that was all the more obvious after the PHE report with 'How Very Dare They!'. Smokers dare because they have given so bloody much to the system in the first place and they have every right to ask for help back if they want it. If a med e-cig provides the leg up to the proper stuff, the grown up and fun stuff then who are we to decide they can't have it based on our own ideologies? 

We have to be flexible, see the merit in things and not be bound by zealousness as so many we are up against are.

Above all?

We don't define peoples choices. They are not ours to define.