Saturday, 12 September 2015

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 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.


  1. I don't know about whether making ecigs free on prescription would actually help people transition off tobacco. One of the many factors which make one a successful quitter is making a small but real financial investment. This is borne out anecdotally by the many, many smokers I have donated kit to, only to find that it ends up in the dresser drawer almost immediately. Having also worked in a small ecigarette B&M for a year, I know that those who spent their $60 - $100 on a starter kit almost all became repeat customers, and nearly always came back with a smoker friend the next time they came to the shop. I'm certain it was at least partially good customer service and personal support and troubleshooting face to face which made the difference between success and failure with ecigarettes. It was never as clear as with couples, where one was "dragged along" by their enthusiastic spouse, and frequently, it was the reluctant partner who became the most outspoken passionate advocate for ecigarettes. I think that's because if you do give them a fair dinkum try, you will stop smoking, often with very little effort and barely any of the resentment that comes from conventional "giving up" methods. My 95 year old grandpa misses cigarettes every day, and he quit in his 50s when my grandma became ill. I started vaping nearly 3 years ago, quit cigarettes completely in 5 days, and after the first few months, I can say in complete honesty, I don't miss cigarettes, at all, not one bit. I can't imagine a scenario where I'd go back to smoking.

    1. You make a very good point about the incentive value of a financial investment in a device, and your experiences very closely mirror my own. But as much as my instinct tells me you are right, I can't discount the theory that there will be people out there who would be assisted (both financially and in terms of confidence) by NHS prescription. One unintended benefit could be, as Markse has pointed out below, to 'legitimise' ecigs in general, and make people more likely to take that important step.

  2. This has changed my way of thinking about the matter. I was against the idea of prescription #ecigs for a few reasons - possible back door to med regs, practically useless products (gen 1), extremely limited choices, pharma cleaning up on profits etc etc.
    What we have to understand is that this is NOT a "one size fits all" solution. So, rather than thinking that a prescribed #ecig wouldn't work for everyone, it would be better to think that it WILL work for some - especially those who won't take the risk of possibly wasting 3 days supply of tobacco just to give it a go.
    I still firmly believe that the most effective way is to be able to approach a knowledgeable and reputable vendor, or a seasoned vaper to get advice and opportunity to try the miriad of combinations that are currently available. You won't get that in a pharmacy, and that is the weakness..
    The best possible scenario would be if SSSs were released from their shackles and had an experienced vaper they could call upon in order to help those who have expressed an interest in #ecigs.
    The more options and alternatives available the better.

  3. Whilst I agree with the principles behind the idea of offering free or low cost ecigs via the NHS (or GP's / Pharmacies) in order to reach those that may choose not to switch for a variety of socioeconomic or societal reasons (such as the 'luxuries' reasoning), the concern I have personally is how this would reflect on the consumer market.

    Let's say for instance that the NHS is providing ecigs (2nd Gen stuff) via the various routes, the perception of them will of course be as a medicine or treatment, and as the statistics for 'traditional' nrt shows, uptake isn't great, nor is the success rate; this I feel is mainly because of the word "therapy". It puts people in the mindset of "something is wrong which needs medicinal treatment" and because some think that of prescribed or NHS provided NRT, it is likely that it would be the same for prescribed or NHS provided ecigs.

    On the flip side, you have the consumer products being sold which may encourage those using the 'medi-cig' to switch to them, but I suspect that the generalised loathing for anything "medicalised" for smoking cessation could also be projected onto the consumer market and may end up having the opposite of the intended effect.

    Theoretically it's a good idea to have an offering via the NHS, though I doubt any 'medi-cig' would ever offer the user the fun and enjoyment that a consumer product does (and some irritation when it comes to rebuilding ;) ), but it does worry me that some may view the consumer products in the same 'medi-cig' light.

    1. I think the consumer market and vapers ourselves are by now so well established that I would be amazed if the existence of a med-ecig made any difference at all to public perception of ecigs in general. To my mind it would be far more likely that the public would think 'hey look, that beardy tattooed rabble were right - and now even the NHS is jumping on the bandwagon'.

      The idea that a late coming medicinal version of something taints the whole category just seems unrealistic to me - it's not as if people stopped buying chewing gum or sweets when nicorette gum and lozenges hit the market.

      My personal view is that a med-ecig will never exist (unless the MHRA drop the bar by a substantial amount) and so this whole discussion is moot. The fact that they haven't yet done so tells me that they don't understand ecigs (no surprises there) and given that they will be the competent authority for TPD regulated ecigs that is by far the more worrying aspect we need to overcome.

      NHS prescription of ecigs is a side show - it might work for some people, it might not but as far as I can see trying doesn't have a downside. There are more important things to concentrate on.

  4. Great posts Lorien and Sarah, thank you. I shouldn't think much more needs to be said about this, but since I was at the same meeting I will add that the notes I took support the points made on this blog. The general tone of the APPG meeting was that the whole issue of prescribing ecigs via the NHS was something of a sideshow relative to the overall content of the PHE report.
    I think it was Earl Cathcart, who said he'd quite smoking after many years with the help of ecigs, suggesting that NHS prescriptions really shouldn't be necessary because most smokers would actually save quite a lot of money switching from cigarettes to vaping. This is the context in which Lorien made the point that a properly-effective device of the kind that long-term vapers were likely to prefer actually represented quite a big outlay of cash, especially for those on low incomes, and that there could be a role for a cheaper ecig made available for smokers wanting to quit, that wasn't a long-term solution for the user but allowed them to have a go and 'prove the concept'. Then I think it was Louise Ross who commented that maybe some free samples could be made available, in the same way that stop-smoking services sometimes provide some NRT products.
    All that sounded extremely sensible and uncontroversial to me, and a long way from arguing that ecigs should be prescribed to all over the long term, let alone seeking that vaping be 'medicalised'.

  5. Surely the free ecig thing is a red herring widely reported as headline news because the papers knew it was controversial? The really big plus side of a prescription ecig would surely be a total legitimisation of ecigs- very hard to argue they are bad if the nhs can prescribe them. This would be a massive win in changing ppls perceptions of ecigs in general, give confidence to smokers who were lied to in the past about ecigs relative harms, and silence the antz once and for all? Well ok not silence them but make their arguments more difficult.

  6. The market for e-cigs has functioned well. Pricing has come down and innovation has gone up. The number of vapers has steadily increased. The introduction of a medecig would complicate matters.

    It is not just a question of prescribing an e-cig. As with other NRT, there would be follow ups, studies, checks on value for money etc.... All this is unnecessary.

    People stop smoking for various reasons, It is very patronising to single out 'the poor'. Rich or poor, people have choices now. Trying to 'help' people who have not asked for help is not really helping, it is a subtle form of coercion. My ecig is ok your medecig is a medicine to help you (because you're poor).

    Have the numbers going to smoking cessation clinics gone up or down? From what I have read they have gone down. Why? People have been provided with information and word of mouth testimony. Why not let this continue and reject the medecig outright? This leaves personal autonomy intact.

  7. Thanks for the link to my report on the APPG.

    Reading this:

    "But a decent starter kit can now be bought for the price of 3 packs of hooky fags, so what is making the difference?"

    Reminded me of our early days selling e-cigarettes at shows. At the time we found that some people loved the idea of e-cigarettes, but just did not have thirty pounds to buy a starter kit, even though they could scrape the money together to buy a pack of fags (admittedly cheaper then).

    However, I do think the argument is fairly irrelevant at the moment as it seems unlikely any company at present is going to be able to get an e-cigarette licensed as a medicine. In fact, if David Dorn is right, the technology doesn't exist to meet the medicalisation requirements.

    1. I agree with you James. Aside from the technology (or lack of) I wonder why any sane manufacturer would want to pay such a large amount of money to produce a product which either a) no one wants or b) will simply be a springboard to better products on the consumer market.

  8. I don't really like to intrude with my ignorant comments, but I find it difficult to resist.
    For a long time, I drank Carling lager. One evening, the pub had run out of Carling and so I tried Fosters. Although I have drank many a pint of Fosters in the past, I was pleasantly surprised that the Fosters' taste was nicer than Carling, and so I switched to Fosters. I might change my mind again in the future.
    My point is that I made the decision and I made it on the basis of pleasure.
    So think about a person who believes the propaganda about smoking harm. Everyone is entitled to believe the propaganda if the wish. Also bear in mind the cost of cigarettes. The cost is real and now, whereas the propaganda is hazy and some time in the future maybe. So the smoker looks around for an alternative to buying cigarettes and finds ecigs. To his astonishment, he finds that they are enjoyable - perhaps even more enjoyable than cigarettes.


    I think that all humans have the tendency to look for the most comforting interpretation of what is happening. For this reason, it is easy for vapers to slip into the jargon of The Tobacco Control Industry. It is easy to slip into the idea that 'ecigs are wonderful for giving up smoking'. What is wrong with that statement? It is wrong because it puts the cart before the horse. The 'horse' is that vaping is pleasurable - stopping smoking, the cart, is incidental.
    The Tobacco Control Industry has no interest whatsoever in the horse, it is only interested in the cart.
    The way I see it is that NHS intervention via recommending ecigs could only work in the form of a voucher system (and definitely not a prescription system). It would have to work similar to the travel voucher system. A voucher could be issued by a GP or Smoking Cessation Office for, say, £20 - enough to buy a simple 2nd gen device and some e-liquid, redeemable at any of a number of local vape shops. The recipient could then seek the advice of the shop owner and try various liquids. Only the participating vape shops could redeem the vouchers. Sure there would be some who take advantage and get themselves some money by trickery, but that is also a risk with travel vouchers.
    My wife is disabled and I can get travel vouchers worth £120 for £30 per an. Imagine that I sell the vouchers to a bent taxi man. What can I gain? If I sell them to him for £60, then all I get net is £30. What's the point in getting £30 over a year? And then what if I need to get a taxi? I would likely be spending more than the £30.

    So it is possible to conjure up a system, but it would have to be very loose. Certainly, the involvement of the MHRA would have to be avoided at all costs.

    Above all, DO NOT PLACE ANY TRUST IN ASH, the RCP or PHE. The are nests of vipers and will turn on you at the blink of an eye.

  9. Thanks Lorien and Sarah for a hugely interesting blog that raises interesting questions. In my opinion NHS provision of e-cigs is a complete red herring. The decision to smoke of vape isn't a medical decision, but a lifestyle choice. Involving the NHS in the supply of e-cigs by whatever method by default sends out a message that none of us really want to see. Namely e-cigs are a medical product. The NHS doesn't provide mobile phones or Sky subscriptions which in fairness the majority of lower income families already have, so why should e-cigs be any different? The real question is should the Government financially support the provision of e-cigs to those that may financially struggle initially to buy a decent starter kit? The next question is why is everyone assuming that the NHS is the only way that this could be accomplished? Look at all the energy saving schemes for loft insulation, new boilers etc that allows private companies to provide a new energy efficient product, which is then subsidized by the Government. Let's not assume that the NHS is the only route to the problem, unless of course this thinking is brought about by the reality that Article 20 has already determined e-cigs to be medical by default?

  10. dear patroller, you stink nazi

    1. dear patroller, yes you are a bigot vecause smoker are human beings and to you they are filthy dirty scum, so qed you sir sound to me like a bigot or a nazi

    2. dear patroller, sir as i see it , you are mistaken, i am no pro smoking lobby type, i am just a average smoker.and i despise anti smokers as a general rule. i am just pointing out that much of what antis are on about is hyberbole, lies statistics and yet more lies. by the by sir you might think as ye sow so shall ye reap.

    3. dear patroller, see you just let slip the mask. you sir must be the most anti-enjoyment kid in your class.what???? cesspit. you are a cesspit. you hate smokers, and probably anyoneelse who disagrees with you
      you need to remember manners ,they cost you nothing and make you les unpleasant to be around.

  11. dear patroller, see you just let the mask slip down a little more.i have a sneaking suspicion you unkind sir, are one of the most unpleasant people i have ever conversed detest smokers? 25% of the global population? well are you not a rare bolt of lightning?now that i think of it you are just a dim-bulb hater. i truly pity you and your failed idea. remember manners cost you nothing and make you a more pleasant person to be around.

    1. The trail of the reaper feeds the crows.

  12. dear patroller, again you shower a person with too much hate.actually my "arguments" are still valid.i have thought out a perfect foil for your hatefest. GOD BLESS YOU sir and have a wonderful day. as my grandfathers on both sides of my family would say:bless your little pea-pickin heart. you are most welcomesir and have a good day.

  13. dear patroller you are not as good as you think you are. i refer you to the mcnear case in the late 1970s. they could not then or ever will prove genetistists have figured out no one variable causes cancer.many different things do however and stress is one of the way what s with all the cussing? did your parents never teach you good manners?ah well just seeing a anti lose their composure is enough fun for me.btw you might remember good manners cost you nothing, and make you a more pleasant person to be around. good day to you sir.