Politics of Evidence or Evidence of Politics?

Tobacco control policy was the topic of John Britton’s Cochrane lecture at the Annual Scientific Meeting of the Society for Social Medicine this year. The lecture noted that the UK is the highest ranked European country in terms of its policies, yet failed to achieve the low smoking rates of Sweden, which is only ranked mid table for policy.[1] This is likely due to a large number of smokers in Sweden switching to using snus, an oral tobacco product. Snus, which is banned in the UK, has a much lower risk of causing severe tobacco related disease than smoking. Thus, while the numbers of nicotine users in Sweden is not remarkably low, the harm caused by such use is. A similar debate now focuses on e-cigarettes.

I was reminded by this lecture of David Nutt’s discussion of the purposes of drug control policy.[2] Nutt, the former head of the Advisory Council for the Misuse of Drugs, argues that policy makers focus on reducing the prevalence of drug use but that they ought to be focused on harm reduction instead. For example, causing the price of a drug or alcohol to rise, through prohibition or taxes, may reduce use among recreational low risk users but may have little effect on those with problematic use or lead them to switch to potentially more harmful drugs or products with lower prices (e.g. [3]).

E-cigarettes have become embroiled in a heated debate. The scientific discussion has intertwined with the political one. Some evidence suggests that it is less harmful than smoking and may reduce smoking prevalence and therefore harm from nicotine use. Nevertheless, the validity of this evidence, and the conflicts of interests involved – much of the research has been funded by both anti-tobacco groups and e-cigarette manufacturers – have been brought into question.[4] For example, a  row emerged recently after a paper in the NEJM showed that e-cigarettes can produce dangerously high levels of formaldehyde,[5] yet this is only at temperatures not typically produced through normal e-cigarette use. A number of critics argued that the paper “was so misleading it should be retracted.”[6] However, there has been suggestions of potential conflicts of interest of both authors and critics.[7] Nevertheless, while this paper is of potential scientific interest, it may not be of much use in formulating e-cigarette policy.

The e-cigarette debate shows no sign of abating soon. We agree with McKee and Capewell who say, ““directors of public health and the wider community desperately need advice on EC [electronic cigarettes] that is evidence-based and free from any suspicion of influence by vested interests”.[4] Indeed, no public health decision should turn on the basis of intuition alone.

 — Sam Watson, CLAHRC Research Fellow

References:

  1. Joossens L & Raw M. The Tobacco Control Scale 2013 in Europe. Sixth European Conference on Tobacco or Health. Istanbul, Turkey, 26-29 March 2014.
  2. Nutt D. Drugs: Without the Hot Air. 1st Edition. Cambridge: UIT Cambridge Ltd. 2012.
  3. King L. Evidence based policy? Why banning mephedrone may not have reduced harms to users. 19 September 2011.
  4. McKee M & Capewell S. Evidence about electronic cigarettes: a foundation built on rock or sand? BMJ. 2015;351:h4863.
  5. Jensen RP, Luo W, Pankow JF, et al. Hidden Formaldehyde in E-Cigarette Aerosols. N Engl J Med. 2015;372:392–4.
  6. Bates CD & Farsalinos KE. Research letter on e-cigarette cancer risk was so misleading it should be retracted. Addiction. 2015;110:1686–7.
  7. Willingham E. Researchers call for retraction of NEJM paper showing dangers of e-cigarettes. 11 September 2015.
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