The trouble with dedicated nicotine-free e-cigarette producers

First of all there is nothing wrong with nicotine-free options for someone who wants them. The problem is that producers and marketers limited to nicotine-free options, particular in a distorted market (as in Canada where most people think there is a ban) tend to leverage the misperception of nicotine as not only harmful but as one of the main reasons smoking is bad for you.

One of these companies, Smoke NV, based in my home town of Edmonton, was featured on a recent CBC podcast discussing e-cigarettes in Canada.

If you happen onto their site, you will read the following on their Why not nicotine? page.

We simply don’t believe that there is any benefit to having Nicotine in our product, further to this, we believe that research shows that it is not needed for a smoker to enjoy this product.

What has been discussed and is growing momentum is the harm reduction view within research. This is an acknowledgement of the fact that the use of an electronic cigarette is simply safer than the use of a traditional cigarette. Essentially for each puff of an electronic cigarette containing no nicotine you avoid a puff from a traditional cigarette. Obviously traditional cigarettes have been shown to cause cancer, heart disease, pulmonary disease etc. (Harm Reduction, Dr Phillips http://www.tobaccoharmreduction.org/faq/ecigs.htm)

The one reference for the research being used to back their claims that smokers do not require nicotine for an effective substitution is quite a strange one out of the University of East London where smokers found that nicotine-free e-cigarettes did alleviate cravings as successfully as regular e-cigarettes. But here’s the kicker. The subjects were smokers (who typically smoked 10 or more cigarettes a day) who had been deprived of smoking for just one hour and then tested 5 minutes after vaping. Somehow I don’t think that reflects true life experience.

The second paragraph is much more insidious.

Leaving aside the issue that they are linking to writing from a resource I participated in creating – tobaccoharmreduction.org – the subtle move from saying that 1. e-cigarettes are safer than cigarettes to 2. because from our product you don’t get nicotine which 3. must have something to do with all those diseases you get from smoking. (This reminds me of the early days of e-cigarette marketing when the ad copy tended to mislead consumers by harping on about being safer because they tobacco free).

Smoke NV has positioned itself as firmly against nicotine and addiction. Sure, their product is better than smoking but if smokers really enjoy nicotine (and somehow I suspect that is the case) NV products are much more likely to have them scurrying back to cigarettes than a good old nicotine delivering e-cigarette would. So potentially nicotine-free e-cigarettes in competition with regular e-cigarettes could actually be harmful to public health.

On a more cynical note, on a recent vapecast discussing the CBC show, it was suggested that Smoke NV was inserting itself into the market and once Health Canada eased up would release nicotine versions. This might be more than likely. Following a link on a recent Siegel blogpost I found myself at the Tobacco Vapor Electronic Cigarette Association.

This is an American version of ECITA (UK) or ECTA (Canada) – an organizations that promote professionalism and compliance among its members. Oddly enough Smoke NV is one of those members. And though I have not looked through all of them, the ones I have are all your average nicotine delivering e-cigarette companies. Need I say more?

In summary, there is nothing wrong in supplying users who want nicotine-free e-cigarettes. They should be an option. But companies like this are insinuating that by virtue of their product containing no nicotine that it is healthier. And there is no real evidence for that.

Even professional harm reduction workers have issues with tobacco harm reduction

Ask any doctor what they would recommend if a patient of theirs who felt compelled to use a drug with proven health risks asked whether it would be better to take another drug which made them feel exactly the same but was a lot safer. Odds are the doctor would suggest switching.

Now ask them about smoking and e-cigarettes and the answer might change.

Though many doctors are coming around the health community as a whole is still experiencing a bizarre disconnect when it comes to nicotine. You can’t even call it cognitive dissonance because they don’t seem to experience any anxiety from endorsing harm reduction in general while rejecting it when it applies to smokers.

A few years ago at a small meeting held at one of the conferences of what used to be called the International Harm Reduction Association I witnessed a similar occurrence which given the context was even more disturbing. The meeting had arisen due to certain influential elements within the organization who wanted to eliminate tobacco harm reduction from their community.

It was very strange to see individuals who had supported safer sex, safer drug injection practices, and safe injection sites, practically foaming at the mouth at the thought of promoting tobacco harm reduction. One of the central objections was that one avenue of harm reduction, smokeless tobacco, was produced by tobacco companies, and these same people who would, if it improved the likelihood of safer practices, collaborate with drug producers and dealers, with difficult anti-democratic bureaucracies, and with pimps, would rather cut off their own hands than join with tobacco companies to find a solution.

When the people who are on the front lines of the battle reject what should be contiguous with their own goals (reducing the harm in risky practices) you have to be concerned about the average public health official.

I don’t want to be entirely negative here. I believe the tide is turning and to a great degree because e-cigarettes arose independently of the tobacco companies. However the companies are buying into the e-cigarette market and you can expect the objections to increase in number.

Most of these objections will be of the “just a way of maintaining nicotine addiction” nature. But guess what – along with the independent e-cigarette companies these “evil” folks are taking pretty well all the harm out of using nicotine. The addiction was never really the issue.

The anti-nicotine forces like to promote the idea that there is something special about smoking, nicotine and tobacco companies.

Not so.

Smoking is just another popular behavior with some safer satisfying alternatives available. Nicotine is just another drug like caffeine that feels good enough to make a difference but not so good that it disrupts the rest of your life. And tobacco companies are no different from any other large corporations that will do anything to keep customers.

When quitting is an option and not a necessity

Though it seems to be so much more common and easier to divide behaviors into good and bad, the problem with drug use is that it is so much more complicated than that. Drug users are as varied as anyone, and since almost everyone is a drug user of some kind, its pretty specious to draw such presumptuous demarcations. Once you replace morality with health (health, in my opinion, actually being the more “moral” approach) more natural and pragmatically useful categories come into play.

Rather opposing abstention and use, why not envision an opposition of bad enough to worry about and not bad enough to worry about. Forgive the vernacular but to me it seems to make more sense than terms like safe or dangerous.

With the dominant mindset we have all nicotine users (whether snus-ers, smokers or vapers) lumped together and on the other side the abstainers. The inappropriateness of this grouping (in the context of public health) is also evident when nicotine users are contrasted with prescription drug users, alcohol consumers or any other drug users. Its just not helpful when someone on anti-depressants or beta blockers criticizes someone for boosting their neural process or relaxing via a dose of nicotine.

But the main point is that the practical division is along the lines of how risky a behavior is. Once health is the measure then we will find that the constructive nicotine use breakdown is smokers on one side and everyone else on the other. (This is not meant in any way as castigating individuals who choose to smoke but is simply a breakdown of what health risks the behaviors are associated with. Its no different that separating high from low risk sports activities. Higher risk activities are not morally suspect; they are just higher risk.)

Once the powers that be stop blocking basic information about the comparative risks of various nicotine deliveries and once people understand that in the long run switching to snus or e-cigarettes is roughly equivalent to quitting then we should see a dramatic increase in switching and we might also see attitudes toward quitting change.

As mentioned in the last post, even if the health risks of using nicotine are perceived as negligible some people will still want to quit -and all the power to them. The point is that people should have the information and they should have the right to do what they will with that information.

What intrigues me is what might happen to the multi-billion dollar cessation industry should the THR message be widely acknowledged. Obviously some of the current cessation products will be reconfigured or remarketed as “dual use”, that is, as either cessation or switching products. (I’m pretty sure this is already taking place to a degree.) This industry, which maintains such mutually beneficial bonds with tobacco control, just might need to disengage in the interest of developing and then promoting products for tobacco harm reduction.

If Big Pharma holds its present course, and tobacco/nicotine use policy moves to being health-based, then the whole cessation industry will become even more like the diet or exercise fad industries – useful for a very small part of the population but a waste of time, money and effort for most. Those industries serve to delay too many people from pursuing the real solutions to their problems.

Most smokers have been browbeaten into believing that they have to try and quit on a regular basis, and many do the quit and relapse dance to exhaustion. (I wonder how much smoking takes place to take the edge of having to contain that identity clash of simultaneously being a smoker and being a quitter.) They have also been misled to believe that pharmaceutical aids to quitting are pretty well mandatory. (See here for Chapman’s critique of the lack of official support for cold turkey; if you are in the market for quitting nicotine, it seems to be the way that has worked for most).

The “official” explanation of the failure rate is that it takes many attempts to successfully quit. I can just imagine the meeting on that one.

“Bob here says the figures show that almost all our customers are failing up to ten times. They do eventually quit but hey, there must be something wrong with our product. And thanks for that Bob but you are looking at it the wrong way. Its not a product problem; its a user profile. The product is perfect. Smokers are just so addicted that it takes that many time to break through their addiction.”

“Maybe they’re just quitting after trying that long and it has nothing to do with our product?”

“Don’t be an idiot.”

Regardless of the THR message being widely accepted or not, these companies will still push their products as being healthier and safer than e-cigarettes and smokeless tobacco. In the meanwhile, most everyone will come to understand that there are few real differences among all these low risk nicotine delivery methods (especially once the smoke clears on the crucial combustion/noncombustion divide). People will also realize they have the power to choose between continued use or quitting with negligible differences in health consequences.

When we reach that point, those who have been actively opposing and obscuring the truth about these products will be revealed for what they really are: not public health advocates, not beneficient guardians of the public trust, but as sadly impoverished abstinence-only advocates. And not only just abstinence-only advocates, but abstinence-only advocates of a relatively benign (and in fact very useful) drug. Here’s hoping that day comes soon.

-Paul L. Bergen

On developing a drug to help mice quit smoking (maybe people too)

New research is being reported out of the Scripps Research Institute on how nicotine works in the brain of mice. We’ll assume for the sake of argument that this parallels how it works in humans.

In the ScienceDaily report we read:

Scientists from the Florida campus of The Scripps Research Institute have identified a pathway in the brain that regulates an individual’s vulnerability to the addictive properties of nicotine. The findings suggest a new target for anti-smoking therapies.

and

The scientists then worked out the biochemical mechanisms through which α5* nAChRs operate in the medial habenula to control the addictive properties of nicotine. They found that α5* nAChRs regulate just how responsive the habenula is to nicotine, and that the habenula is involved in some of the negative responses to nicotine consumption. So when α5* nAChRs do not function properly, the habenula is less responsive to nicotine and much more of the drug can be consumed without negative feedback from the brain.

The scientists are optimistic that their findings may one day lead to help for smokers who want to kick the habit. Based on the new findings, the Scripps Florida scientists have started a new program of research in collaboration with scientists at the University of Pennsylvania to develop new drugs to boost α5* nAChR signaling and decrease the addictive properties of nicotine.

Or let’s take a look at that same story in CBS, one of the minor reporting dialects common elsewhere on the web:

They hope to find a drug that will help smokers attack the addiction in an entirely new way. They are hoping to find a way to make smokers have a bad reaction to a cigarette and be slightly disgusted by it. They are hoping the drug will take all of the pleasure out of smoking, and thus, stop the urge to smoke.

The National Institute of drug abuse gave Scripps an 8 point 2 million dollar grant to develop drugs to literally kill the nicotine buzz.

Scientists say when someone first starts smoking, there is a natural nasty feeling that goes away as people smoke more often.

The grant gives scientists five years to develop drugs and Scripps is confident they will be able to develop a handful of pills that will finally get people to quit.

Now, that’s some fine writing!

But it did convey the little item about the substantial multimillion dollar grant to develop another smoking cessation tool. In a forthcoming post I’m going to address the point of how useful yet another of these quit smoking approaches might be given that we now have so many many alternatives that almost entirely remove the risk associated with using nicotine. At the least, these alternatives (such as smokeless tobacco or electronic cigarettes) reduce the health risks to the degree that in the long run there is little to distinguish use from abstention. But in the meanwhile….

The first question I have about this research is whether the currently dominant view of nicotine as a scourge is skewing the interpretation of their findings. How do we not know that this so called malfunction might in fact be a useful adaptation? If someone’s brain functions better on nicotine then wouldn’t it make sense that there would a compensating mechanism of allowing in the very thing that improves function?

There is just a hint at appreciating this with the absurdly obvious observation from one of the scientists involved in followup research:

“It has beneficial effects on anxiety and attention, among other things, thus making quitting very difficult”.

In other words, we have to work exceptionally hard to create just the right intervention to help you successfully wean yourself from something that is actually making your life better.

People use and quit drugs for many reasons. There are people who feel they need to quit caffiene. Not because they are suffering in any way but they don’t like the feeling of being in thrall to the drug. Though the occasional article surfaces about the potential negative effects of caffeine use few people end up thinking it is all that bad for you. But there are and always will be people obsessed with quitting it. And no matter how safe nicotine delivery becomes, and if you get away from smoking it, it is right in that caffeine ballpark right now, there will always be people obsessed with quitting it as well.

Now, the question is this. What would you think if NIDA granted a company 9 million dollars to develop a pill that you could take to make your morning cup of coffee cause you to chunder?

-Paul L. Bergen

Removing the addiction myth is a good first step

I just read two very different articles, one on the pitfalls of the addiction myth from a smoker’s perspective and the other about prison libraries as a valuable resource. What they share is a perspective on how healthy options can proceed best from non stigmatized arenas.

In the first, from Underdogs Bite Upwards:

If the NHS really wanted to help people stop, they would play down the addiction story. They would tell you that stopping is just a matter of not doing it any more. Instead they hype it up until you believe you will pass through the very fires of Hell after stubbing out your last one. That approach almost guarantees the smoker will fail. Those feelings of nervousness and twitchiness and irritability are not caused by lack of nicotine. They are your mind’s response to being convinced that you are about to suffer terribly from something you can’t quite identify. The whole smoking-cessation industry is designed to fail. It is designed to keep its staff employed and to do that it needs smokers to keep smoking.

and

I’ve read Allen Carr’s ‘Easyway’ book….you’ll find in there a passage where he tried to start smoking again to see if his method would work on a relapsed smoker. He couldn’t start again. He didn’t enjoy it.

Well, we’re not supposed to be enjoying it. We’re supposed to be slavishly addicted to it. One cigarette causes addiction, isn’t that the mantra? So how come Carr couldn’t restart on the grounds of not enjoying it?

Carr’s success rate was down to his method being voluntary. People went to him because they wanted to stop. The NHS success rate is paltry because they push people into stopping. They are forcing people to stop doing something they don’t want to stop doing.

The belief in being addicted not only locks the user into continuing even if they no longer feel like it but probably makes it less likely for them to consider safer nicotine alternatives. Underdogs stresses the point that keeping the addiction perspective strong bolsters the pharmaceutical industry, and while I agree with that, I think just as much that, unless you can free yourself of that belief like Carr did, it is just as likely to keep you smoking, and keep you coming back to smoking.

If after weighing the pros and cons of the behavior, you can smoke or not, based more on whether you enjoy it or not and not because you think you have little choice in the matter, you are free to make the better decision. You will also be more open to those safer alternatives rather than painting nicotine use as a prison you need to escape from.

Which brings us to the Boston.com article on prison libraries. In general, the point is that prisoners use the library for many purposes other than sourcing educational materials; some watch movies or read glossy magazines, and some use it as a place to leave letters for other inmates. But many coming to the library for other reasons end up being exposed to and then attracted to the more traditional uses of the library. They come to see it as a nonjudgmental space in which they can begin to move beyond their circumstances.

Libraries, like the idea of a world beyond addiction, are new ideas to many people, many of whom are best situated to profit from those ideas. Both libraries and stigma free nicotine use open up the arena for people to take charge of their own behavior, to determine their own best futures, and to break free of the stultifying patterns that have kept them enchained.

– Paul L. Bergen