Category Archives: nicotine replacement therapy

The perfect ‘product’ for nicotine addiction

The US Food and Drug Administration (FDA) recently announced it has awakened to the interesting idea that the way to help people quit smoking is for them to have a wider range of ‘products’ available in addition to so-called nicotine replacement therapy (NRT).

The FDA recognises that NRT (nicotine-containing gum, patches and lozenges) is of limited effectiveness and so it now wants the smoking public to have access to more options, in particular, e-cigarettes. Further, it wants to have NRT and e-cigarettes approved as medical products and possibly even have them covered by health insurance.

Let’s pause for a moment to consider this curious situation. In the US cigarettes are freely and legally available for sale to anyone over 18 (21 in some states). As a result many people become addicted to smoking and because of this there are about 480,000 deaths from smoking-related diseases in the US every year. And the way the government is trying to deal with this is that when people are already addicted to the nicotine in cigarettes and find it difficult to stop smoking, they should be offered nicotine in some other form as a ‘therapy’ to help them. But because NRT doesn’t work very well they need to have other products or options available as quit smoking aids.

Isn’t there something a bit odd about this? Either nicotine-containing consumer products (especially cigarettes) should cease to be available, in which case the problem wouldn’t arise for those who don’t yet smoke, or we need a radical new approach to treating nicotine addiction for those already in this unfortunate position.

It gets worse. The FDA is contemplating new measures that would enable cigarette companies to get non-cigarette nicotine-containing products approved as medicines to treat the nicotine addiction that their primary product, cigarettes, caused in the first place.

Big Tobacco must love this. They can present themselves as part of the solution to the smoking problem – a win-win situation for them because they can anticipate their income will be protected as sales of cigarettes fall while sales of alternative nicotine products rise. This might just about be acceptable if they were to announce, for example, that at the stroke of midnight on 31st December 2020 all cigarette production in the US will cease. Of course they won’t commit themselves – any suggestion of phasing out combustible tobacco products is projected to some vague time in the fairly distant future.

Tobacco companies should be seen for what they are: the whole of the problem. And the only role they can have solving it – and it would be a very big role which would virtually eliminate the problem – would be to stop making cigarettes.

Instead of pushing for this obvious measure, or even mentioning it, the FDA Commissioner, Dr Scott Gottlieb, verbosely talks about ‘what we can do to create additional pathways to bring additional nicotine replacement therapies to the market’.

By the time smokers are addicted to nicotine it’s too late. Dr Gottlieb is pursuing a non-existent goal. You have to remove the cause of nicotine addiction, not treat it when it’s happened. Why aren’t smokers clamouring for relief, for a ‘product’ or even for a range of options to help them escape their thraldom to nicotine?

Because the tragedy of nicotine addiction is that many sufferers don’t want to escape.

Text © Gabriel Symonds

Oyez! Oyez! Learn to love your lungs!

The Nursing Times (13 November 2017) brings us news of a great way to raise awareness of lung cancer for the citizens of the historic city of Leicester in England.

Specialist nurses will run a stall at a shopping centre where they ‘will be promoting e-cigarettes to the public…as part of efforts to boost smoking cessation.’

One of these highly skilled nurses, Sharon Savory, says: ‘We want to show the public what to look for, who (sic) to see and to learn to love their lungs.’

The key message, we are informed, is that ‘using e-cigarettes are (sic) a “great way” to reduce the harm caused by smoking tobacco.’

Then there’s the cheerful news that on the appointed day, ‘Everyone is invited to take a break from their shopping to learn about the early signs and symptom recognition of lung cancer.’

We also hear from the well known Leicester e-cigarette enthusiast, Louise Ross: ‘We know that vaping is at least 95% safer than smoking, and that people who switch to vaping do very well with their quit attempt.’ I have written about this down-to-earth lady before: http://nicotinemonkey.com/?p=1620

The advice given by Ms Savory, bless her cotton socks, is somewhat restricted. Why should you learn to love just your lungs? What about the rest of your anatomy? The marvel of the human body is that, in health, everything works in perfect harmony with everything else. And smoking, though it obviously affects the lungs, also has widespread harmful effects on the blood, heart, brain, stomach and indeed every organ and system of the body.

What she says is just a slogan, of course, but it would be a better slogan, surely, if the intention is to discourage smoking, if it was something like: ‘Love your life’, ‘Respect your body’ or ‘Your body is the temple of God. Don’t desecrate it by smoking.’

Apart from this, there’s something unseemly about nurses trying to promote e-cigarettes. To start with, it’s incorrect to say ‘we know vaping is at least 95% safer than smoking’. Nobody can say they know this; it’s merely an unproven assertion.

The specialist nurses should be more aware than most people that to inhale e-cigarette vapour many times daily for years on end, as vapers typically do, could be a disaster; we just don’t know what the long term effects will be, and can’t know, until probably another twenty years.

And to say ‘people who switch to vaping do very well with their quit attempt’ is paternalistic and meaningless.

By all means let nurses and anyone else so inclined try to boost smoking cessation. But why do they think the best way to do this is to encourage the use of e-cigarettes? Are other methods no good? Or, if they really believe in this defeatist position, at least let them be open about what it is they’re offering.

What they will be saying at their shopping centre stall to the smoking public on the appointed day, although they appear to be unaware of it, in effect is this:

Oyez! Oyez! All persons having business with smoking come hither. Smoking puts you at serious risk for getting the horrible disease of lung cancer. If you stop smoking you will greatly reduce this risk. You need to understand that the only reason you smoke is because you are addicted to the nicotine in tobacco. If you feel you cannot do the obvious sensible thing and quit smoking forthwith, however, you might consider an alternative way of continuing to be addicted to nicotine that is, we hope, safer than smoking, namely, using e-cigarettes.

There’s a further unfortunate aspect to Ms Savory’s words: it’s reminiscent of the advertisement for ‘LeoLites’ e-cigarettes (illustrated), which was banned in Britain in 2014 because it was deemed to imply that e-cigarettes were beneficial to the users’ health.

Before our specialist nurses get carried away by their eagerness to encourage these new drug delivery devices, apart from the unknown risks of using e-cigarettes, perhaps they should consider whether anyone needs to be in a drugged state with nicotine at all?

Text © Gabriel Symonds

The attempt and not the deed, Confounds us

The 2017 version of Stoptober, as they call it, finished on 28th October. The idea was that if smokers could be encouraged and supported not to smoke for twenty-eight days, they would be ‘five times more likely to quit for good’.

Those who signed up received daily messages of the following kind:

If you’re using stop smoking aids, including e-cigarettes, remember to keep using them.

Count up how much money you’ve saved so far, since quitting smoking

Write down the times when you’ve beaten a craving, or turned down a cigarette. You did it then, so you can do it again, and again.

Keep reminding yourself of all the reasons why you decided to stop smoking.

Having trouble sleeping? Try introducing some activity into your day. A kick about with the kids, a Zumba class, or a brisk walk could really help.

As I said in an earlier post, it’s not my intention to knock the campaign – any way that helps smokers to quit is to be welcomed.

However, is such a campaign the best way to go about it? If this approach were directed to, say, weight reduction in overweight people, it would make some sense. It’s not fully understood why people become overweight and slimming is difficult. Even so, daily encouragement to stick to a diet could be helpful.

With smoking, on the other hand, as far as I recall, the word ‘addiction’ isn’t mentioned and the approach of the campaign implies that people smoke for lack of motivation in stopping.

They claim that

Stoptober has driven over 1 million quit attempts to date and is the biggest mass quit attempt in the country. It is based on research that shows that if you can stop smoking for 28-days, you are five times more likely to stay smokefree for good.

What’s the good of a quit ‘attempt’ and what does it mean anyway? A little thought shows that it’s meaningless. Someone either smokes or they don’t. The idea of a quit attempt – as I have said before but it’s worth repeating – colludes with smokers that as long as they’re ‘trying to stop’ everything is fine. But it’s worse than that. The concept of trying to stop implies it’s going to be difficult – you have keep trying, as in the story of Bruce and the spider. Such an idea is reinforced by the advice to use a ‘stop smoking aid’ (it’s too difficult to do on your own) and that you will need support to overcome ‘cravings’ (scary).

And what’s all this about being five times more likely to stay smokefree (sic) for good if you can stop smoking for 28-days? Five times more likely than what? What research they are referring to? I wrote and asked them; I am still waiting for a reply.

This doubtless well-intentioned campaign does nothing to help smokers understand why it seems so difficult to quit. Further, it’s discouraging, because it reinforces the notion that a tough time lies ahead and that smokers need to use willpower to refrain from smoking for twenty-eight days. And then what’s supposed to happen? You will have to continue to use willpower for the rest of your life?

It’s even more unfortunate that this year e-cigarettes are recommended as a way of stopping smoking. As I have also pointed out before, this is misleading or at best a half-truth. E-cigarettes provide an alternative way of taking nicotine into your body that, it is hoped, will be safer than smoking. But people who take this route to smoking cessation continue to be addicted to nicotine. It’s defeatist and almost insulting to smokers to suggest they use e-cigarettes. At least with other stop smoking ‘aids’, such as nicotine patches and chewing gum, there’s a limit to the time one’s expected to continue with them – though not a few use them long-term.

On the other hand, if you go about it the right way you can stop smoking easily without any so-called aids and even willpower is not required.

Text © Gabriel Symonds

(The title is from Macbeth.)

Can’t see the wood for the trees – or the nicotine for the e-cigarettes?

A headline in today’s online BBC news (so it must be true) announces ‘E-cigarettes: Cross-party group of MPs launches inquiry’.

The main point of this exercise is to try and fill the ‘significant gaps’ in what is known about e-cigarettes including how effective they are as a stop smoking tool and how they are (or should be) regulated. But it’s curious that these ideas are put forward as a reason for an inquiry – because what is already known about e-cigarettes together with what can be reasonably surmised is enough to make such an inquiry unnecessary.

E-cigarettes should first of all be seen, not as a stop smoking tool, but for what they are: a supposedly safer way for smokers to continue their nicotine addiction.

There are almost three million vapers in the UK and about half of them smoke as well. In other words, for these people vaping is an alternative or additional means of taking nicotine into their bodies. But why is it assumed, for smokers concerned about the dangers of smoking, that an alternative is needed at all? Recommending e-cigarettes is becoming almost a knee-jerk response for those seeking help to stop smoking.

The enquiry might better look into these questions: Why do people smoke? Why does it seem so hard to stop? Do smokers really want to stop anyway, and if not, why not? Is it or should it be public policy that millions of vapers in the UK are in the thrall of long-term nicotine addiction?

E-cigarettes are supposed to be safer than smoking, but it’s patronising and almost insulting   to encourage smokers to use them. It amounts to saying, ‘There, there, you poor smokers, it’s too hard for you to quit. But never mind, you can carry on being addicted to nicotine in a way that we hope will be less damaging to your health!’

Now, suppose we could anticipate the result of our cross-party group of MPs’ inquiry over the next few years or decades (because this is how long it will take for a definitive answer  into the health effects of e-cigarettes) and that this will be: vaping is completely harmless! That is to say, it will be found that e-cigarette vapour, which consists of nicotine, water, flavourings, propylene glycol and glycerin, as well as trace amounts of cancer-causing chemicals and heavy metals, even when inhaled into the lungs many times daily for years on end, poses no danger whatsoever to the vaper or those around him or her including babies, children and pets.

Further, let’s anticipate that the originators of the slogan ‘E-cigarettes are 95% safer that smoking’ were over-cautious in arriving at this figure and now it can be said with complete certainty that e-cigarettes are 100% safer than smoking!

These statements of course are fantasies. But let us assume for the sake of argument that these conclusions are true. Therefore, if e-cigarettes are to be promoted as a stop-smoking tool, putting aside the question of whether they should be allowed at all, then it follows that since ordinary cigarettes are certainly not safe (they kill around half of all smokers) the action that needs to be taken on public health grounds is obviously to ban ordinary cigarettes at once.

And if we further suppose for the sake of argument that the results of future research will show that e-cigarettes are, indeed, 95% safer than ordinary cigarettes, or that they are, say, only 50% safer, then the argument to abolish ordinary cigarettes forthwith still would apply.

Even to a sceptic such as I it’s unlikely that e-cigarettes will turn out to be equally or more dangerous to users’ health than ordinary cigarettes – but they could be. See my post on ‘vaper’s lung’ (http://nicotinemonkey.com/?p=1406).

Now let’s consider the second reason why our parliamentary representatives feel the need for an inquiry into e-cigarettes: how they are regulated.

Current regulations limit the concentration of nicotine in the e-liquid, the size of the refills and the requirement that a label must be affixed to the product warning purchasers it contains nicotine which is highly addictive. So far so good, or bad, but in addition, in the UK only people over 18 years of age are permitted to buy e-cigarettes. However, just as with ordinary cigarettes, that won’t stop any enterprising youngster who wants to vape from obtaining the kit and doing so – indeed, it’s a serious problem that so many children vape and smoke and thereby become addicted at a vulnerable age and go on to become regular users of nicotine. So, regulation with the intention of preventing people under 18 from vaping or smoking or both, is largely ineffective. With this in mind, it’s relevant to ask how does our group of parliamentarians anticipate changing or tightening the regulations, and why?

There’s a much more effective way of stopping smoking than turning to other nicotine products. It needs to be remembered that smoking is largely a psychological problem. This was recognised in the US as long ago as 1964 in the seminal Report of the Surgeon General on The Health Consequences of Smoking:

The overwhelming evidence points to the conclusion that smoking—its beginning, habituation, and occasional discontinuation—is to a large extent psychologically and socially determined.

How to use this knowledge to achieve simple smoking cessation has been set out in my books, available the publisher and Amazon.

Text © Gabriel Symonds

Inhale Poison to Stop Smoking: Official

Since I’m on the mailing list, I’ve once again started receiving notices of the forthcoming 2017 version of the so-called Stoptober anti-smoking effort put out by Public Health England (part of the UK Department of Health).

It’s not my intention to mock this campaign. Smoking is a serious problem and anything that helps people to quit is to be welcomed. However, as in previous years, the approach used lays itself open to parody.

The first message encourages me to ‘keep motivated’ to stop smoking. (I am of course a non-smoker and have signed up purely for professional purposes.)

Let’s have a look at this phrase, because it contains within it one of the many paradoxes of the current official attempts to deal with the smoking problem.

Encouragement to keep motivated suggests that smokers are in a similar position to middle-aged couch potatoes who should get off their backsides. One certainly needs motivation to overcome one’s natural resistance to exercise and start on the road to fitness.

Smokers, however, are not in this situation at all. Is the reason they smoke because they lack the motivation to quit? Is it believed that if only smokers could increase their motivation to a certain degree, this would tip the balance so they would actually quit? Most smokers have plenty of motivation already – they don’t want to get lung cancer after all – but they seem to be unable to act on it. Why is this? Insufficiency of motivation is not the problem.

Stoptober seems to be trying to persuade smokers they ought to stop, as of course they should. But is this the best way to go about it?

The sub-text is that if only smokers realised the risks they run by continuing to smoke, and if only they could appreciate the benefits of quitting, then they might be sufficiently motivated to make a quit attempt. This approach is based on logic, common sense and the need to use willpower to refrain from the apparently irresistible urge that smokers have to keep smoking. Then, with the increased motivation to be provided by the twenty-eight daily inspirational  sound-bites (or whatever they will turn out to be) of this year’s Stoptober campaign, the participants – if they can only hold out for twenty-eight days – will find themselves in the fortunate position, like the chance to be entered into a lottery, of being five times more likely to quit! This curious statement is from the Stoptober 2016 version, of which my critique can be found at: http://nicotinemonkey.com/?p=842

The next message asks, ‘Have you got a Quit Buddy?’ This means ‘Someone you can call on when you need help’. There we go again: stopping smoking is too difficult to do on your own, so you need someone to call on when (not if) you need help. How encouraging! And what is that someone supposed to do? Say ‘There, there, don’t worry, the horrible cravings and urges will soon pass! Stay strong! You can do it! Remember, if you can survive for twenty-eight days, you’ll be five times more likely to quit for good!’

Today’s message is as follows:

Have you thought about using a stop smoking aid? There are lots of aids to help you quit, including prescription tables (sic), NRT (such as patches, gum, lozenges) and even e-cigarettes. Talk to your GP, pharmacist, local stop smoking service or vape shop to find out more.

Why should a smoker need an ‘aid’ to quit? Again, the implication is that it’s too difficult to do on your own. However, the suggested aids for 2017 are not just the same old nicotine products and prescription drugs, but now we even have e-cigarettes! One way to find out about these is to pop along to your local vape shop.

This is where I must part company with Stoptober. It speaks of the ineffectiveness of the previous Stoptober campaigns (they started in 2012) that they have to throw in a new way of keeping your nicotine addiction going. And vape shop owners must be rubbing their hands in anticipation of juicy profits at this now official endorsement of their products. I think it’s highly irresponsible.

As I have said before, proffering e-cigarettes as a stop-smoking aid is misleading. For many smokers who take up vaping, it merely amounts a new way of continuing their nicotine addiction, maybe indefinitely. Whether it’s really less harmful than smoking only time will tell.  See http://nicotinemonkey.com/?p=1406

Text © Gabriel Symonds

Yummier Than Fruit

There is no doubt that e-cigarettes are big business.

The flyer I received recently about the forthcoming Vapexpo conference in Paris lists around two hundred brands of e-cigarette liquid from sixteen countries.

Promoted on the misleading meme that e-cigarettes help smokers quit, if anyone has any doubts that vaping is drug addiction by other means, they only need to look at the two-minute promotional video for a variety of e-cigarette liquid, produced in Malaysia, with the apt name of  Nasty Juice.

It opens with disconcertingly close-up and slow-motion views of a young man biting into an apple, a strawberry and a mango, in that order, while his eyes roll back in ecstasy. Then the tempo changes as he appears to be in some distress with his hands on his head and the voice-over asks, ‘What if, what if we can make it yummier?’ The answer seems to descend from heaven as, with a look of bliss on his face, he reaches up to grasp – a can of Nasty Juice! This, the voice-over intones, has ‘more flavour, more sweetness and more juiciness, just for you’. And finally the punch-line: ‘Quitting smoking cigarettes is possible than ever (sic)’.

If you wish to enjoy eating apples, strawberries or mangos, you merely need to visit your local fruit shop and buy them, provided they are in season. I often do this myself. But you would have to be out of your mind to buy synthetic chemical essences of these flavours and inhale them into your lungs. Yet this is what e-cigarette users do, and not just occasionally, which would be bad enough, but many times every day for years on end. Nasty juice indeed.

Is vaping safe? The obvious answer is ‘No’. The function of our lungs is to absorb oxygen and to exhale carbon dioxide produced by the body’s metabolism. Therefore, normally only clean air should be inhaled. E-cigarette vapour typically contains nicotine, water, propylene glycol, glycerin, flavourings and traces of heavy metals and other nasty chemicals.

How can one prove that vaping is, or is not, safe? You can’t. There is no reliable way of speeding up the process of long-term exposure to e-cigarette vapour to produce in a few weeks or months what the effects of daily vaping would be in humans after, say, twenty years. This doesn’t prevent scientists from trying, though.

There was a report in the doughty Mail Online (12 September 2017) of a study carried out by intrepid researcher Dr Pawan Sharma from the University of Technology, Sydney. The headline breathlessly informed us: ‘Vaping in pregnancy increases a child’s risk of asthma even if the e-cigarettes are nicotine free.’ In mice, that is.

Isn’t it enough on common sense grounds that vaping is likely to be bad for your health and even more so for pregnant women and their babies? But suppose Dr Sharma’s study had found no harmful effects of vaping in mice, would that mean it’s safe for pregnant women to vape away as much as they like? Obviously not – mice are not the same as humans and it’s an absurd and groundless assumption to regard animals as valid ‘models’ for human illnesses.

Dr Sharma admitted as much because, when I wrote and asked him to please tell me what is the scientific basis for believing that the results are applicable to humans, he was honest enough to reply: ‘These results can’t be extrapolated to humans right away.’

Then why did he do the experiments in the first place? Nonetheless, does he think the results might be extrapolatable (able to predict what happens in humans) in the future, and if so, when, and why? Of course I heard nothing further from this seeker after the truth.

Researchers working for Big Tobacco, on the other hand, are striving to prove the opposite: that tobacco products such as heated (not burnt) tobacco ‘sticks’ (for example, iQOS and ‘glo’) are potentially less harmful than smoking in humans. See http://nicotinemonkey.com/?p=1642. At least Philip Morris, the subject of this post, are cautious enough in their lawyerly fashion only to refer to this new-fangled way of poisoning yourself with tobacco as a potentially reduced risk product.

You can ‘prove’ anything you want with animal experiments. They should be seen for what they are: crude, cruel and useless for understanding human diseases.

Vaping should also be seen for what it is: a way of continuing nicotine addiction that it is hoped will be safer than smoking.

Text © Gabriel Symonds

The Great E-cigarette Confusion

Action on Smoking and Health (ASH) with its punny acronym of a name seems reluctant to embrace the only action that would solve the smoking problem once and for all: calling for banning tobacco. I recently asked their Chief Executive, Ms Deborah Arnott, by email, twice, whether this is ASH’s policy, and if not, why not. The answer was no reply. Or the reply was no answer.

Instead, the action that this organisation seems to favour is of the following kind.

Deborah Arnott:

There are currently 2.9 million e-cigarette users in Great Britain, over half of whom have quit smoking. E-cigarettes are playing an important role in supporting smokers to switch from tobacco smoking…As the market continues to develop we hope to see products go through the more stringent licensing process and become licensed as medicines and available on prescription. (Source: ASH Daily News 4 July 2017)

The sentence ‘E-cigarettes are playing an important role in supporting smokers to switch from tobacco smoking’ is muddled.

Presumably Ms Arnott means ‘E-cigarettes can help smokers switch from tobacco smoking to e-cigarettes’ but this isn’t very satisfactory either. Let me try again. ‘E-cigarettes have a role (we can forego the ‘playing an important role’ cliché) in helping smokers switch from smoking to other, allegedly safer, ways of satisfying their nicotine addiction.’

The end of the paragraph is more promising but likewise doesn’t seem to have been properly thought through.

If alternative nicotine products (alternative to cigarettes, that is) become licensed as medicines and available on prescription, that implies they won’t be available for the general public to buy in every corner-shop and supermarket. And they will, presumably, be prescribed only for a limited time – the time that it will be deemed sufficient for a smoker, having switched to an alternative product, then to stop using that product in the same way that patients stop using a prescribed drug when the have recovered from the illness for which it was prescribed.

This same sentence also shows confusion about the idea of products being licensed as medicines. Although it certainly has effects on the human body, nicotine has no current orthodox medical use – unless one stretches the concept to include treatment of nicotine addiction. But this would be contradictory because it would mean using nicotine for a limited time to treat nicotine addiction!

But if it is accepted, as it seems to be by the likes of Ms Arnott, that medicinal nicotine can legitimately be used as an indefinite treatment for cigarette-induced nicotine addiction, then we shall have the situation where doctors – presumably the burden will fall on GPs, who already have more than enough to do – will have to take on the new task of treating nicotine addicts, that is, smokers, who will likely flock to them for prescriptions for cigarette replacement therapy.

This defeatist and muddled thinking over using e-cigarettes to stop smoking is all too widespread. Even as far away as India, where a number of states have banned e-cigarettes, The Indian Express (3 September 2017), quotes unnamed experts as saying: ‘E-cigarette ban wipes out less harmful alternative for smokers.’

It does not appear to have occurred to these experts that not only is there a less harmful alternative for smokers, there is a completely harmless alternative for smokers: not smoking at all. And no one needs any nicotine product as an alternative for smoking!

In any case, are e-cigarettes really so much less harmful than ordinary cigarettes?

Other Indian experts think not. I quote again from The Indian Express:

…the Union Health Ministry has recently ruled out acceptability of e-cigarettes in the light of research findings by experts who concluded that they have cancer-causing properties, are highly addictive, and do not offer a safer alternative to tobacco-based smoking products.

So there. Ms Arnott please note.

Text © Gabriel Symonds

Photo credit: Wikimedia

Stigmatization and the Corner Shop

When I used to work in obstetrics (care of pregnant women) certain routine tests were carried out at each attendance, such as checking the urine and measuring the blood pressure. The reason was that these tests can give early warning of serious problems such as diabetes and high blood pressure, and then the appropriate action could be taken.

Of course, medical practice doesn’t stand still; sometimes new tests are added and old ones discarded. The latest development in obstetrics, in Britain at any rate, is that at the first and possibly subsequent ante-natal appointments, as part of the routine, a woman should now expect to be breathalysed (unless she opts out) for carbon monoxide (CO). This is to detect pregnant women who smoke and may try to conceal the fact.

What if the test is positive? Assuming the machine is accurate it could be due to a faulty boiler at home or living near a main road, but the most common reason is, of course, smoking. So what is the midwife supposed to say? ‘You naughty girl, you’re a smoker aren’t you? I know you are, the machine proves it! Well, don’t worry, we’ll refer you to your friendly local stop smoking service and they’ll help you to be cured of your nicotine addiction by using a nice nicotine patch or delicious nicotine chewing gum, even though they won’t work very well, instead of smoking those horrid ciggies!’

In the past, if I came across a pregnant woman in my clinic who smoked, I would tell her plainly though politely, that she had to stop smoking today because otherwise she would harm her baby. Paternalistic? Yes. Authoritarian? Yes. Did it work? I hope so.

These days it seems paternalism and authoritarianism are politically incorrect, and instead so-called nicotine replacement therapy is offered. Is it safe in pregnancy? At present there is no evidence that it isn’t safe, which is not the same thing as saying there is evidence that it is safe. And if pregnant women are not wild about using nicotine patches or gum, what about e-cigarettes? Again, although there is widespread belief that these are safer than smoking, there is so far no evidence that this is so.

Now, a professor of health policy at the University of Stirling in Scotland, Linda Bauld, who is also the deputy director of the UK Centre for Tobacco and Alcohol Studies, is quite enthusiastic for pregnant women, if they can’t or won’t stop smoking, to switch to nicotine replacement therapy or to e-cigarettes. Nonetheless, in a recent video talk she rightly sounded a note of caution: ‘What do we know about vaping in pregnancy? Very little, at the moment.’

With her impeccable credentials – although it’s unlikely she has personally treated a single smoker – you would think she would know a thing or two about smoking, but a tiny doubt arose in my mind when, in the same video, she said this:

Pregnant women universally, despite the fact that they find smoking beneficial and enjoyable perhaps before they’re pregnant and still smoke to cope, experience a significant degree of stigma [because others disapprove of their smoking]…we think women [in pregnancy] should be supported to vape if they find it difficult to stop smoking…

It’s regrettable that the bearers of the next generation should be stigmatised in any way, but would Professor Bauld be so good as to tell us why she thinks pregnant women find smoking beneficial, what exactly is enjoyable about smoking for them, and how and with what does smoking enable them to cope? Further, Professor Bauld is evidently unaware that all smokers find it difficult to stop – that’s why they smoke.

If the reason smokers, pregnant or otherwise, smoke is so profoundly misunderstood, what hope is there for getting them to stop? And why should she refer approvingly, as she does, to the new regimen of routine CO breath tests in ante-natal clinics? Does she think that shaming pregnant women who smoke by presenting them with their CO read-outs is the way to reduce their universal stigmatization?

Unless the real reason for smoking is recognised and confronted, the present ineffective and little-liked proffering of medicinal nicotine products and, as Professor Bauld hopes in the near future, prescribing e-cigarettes, will allow the present scandalous situation to continue where any pregnant woman is free to smoke as much as she likes or feels compelled to do.

In her enthusiasm for vaping, Professor Bauld even jumps into the controversy over e-cigarette users having their life insurance premiums loaded in the same way as smokers.

In response to a piece in the online Sunday Post (6 August 2017) that complained that ‘Insurance companies are still hitting e-cigarette users with a “smoker’s surcharge” despite…reports which claim vaping is far less dangerous than using tobacco’, she said ‘Insurers classing people who use e-cigarettes as being the same as smokers is “fundamentally wrong” [and] it is just not fair.’ She added:

As well as being financially punitive to people who vape, it can also send negative messages to those who want to stop smoking…If vapers are regarded as being the same as tobacco smokers it could lead to an attitude of ‘why bother’ and before you know it they are back at the corner shop buying cigarettes.

Here we have it again: the lack of understanding of why smokers smoke and vapers vape. She apparently thinks vapers only vape because they may find some financial advantage in doing so, but if they’re going to be treated in such an unfair way by their insurance companies there’s no point! Why should I stop smoking – that beneficial and enjoyable activity that helps me to cope! – for the sake of my health if I’m going to be hit with extra charges for doing so? I’ll show them! Back to the corner shop!

Even if e-cigarettes are eventually proven to be safer than smoking, in the meantime I can’t say I blame the insurers for loading the premiums of people who suck poison into their lungs all day.

But there’s a win-win situation for would-be non-smokers and all who have switched to e-cigarettes as a less harmful way, they hope, of continuing their nicotine addiction: stop smoking and all use of nicotine products.

The gimmick-free way to do this is easier than you might think.

Text © Gabriel Symonds

Mrs May to the Rescue!

My blog Mrs May – Save Us! was a critique that I wrote in January 2017 of an appeal by a group of 1000 doctors to the UK Prime Minister and Health Secretary to publish a new Tobacco Control Plan: http://nicotinemonkey.com/?p=1175.

The government did so, in rather a hurry it seems, in July 2017. The details are set out in a paper called Towards a Smokefree Generation. It’s self-congratulatory, repetitive, contradictory and, alas, contains nothing new.

Let’s start with the Foreword by one Steve Brine, Parliamentary Under Secretary of State for Public Health and Primary Care.

He proudly notes:

Since the previous Tobacco Control Plan, smoking prevalence has substantially reduced; from 20.2% of adults smoking at the start of the plan to just 15.5% now, the lowest level since records began.

And then he goes on to boast of  ‘world leading public health measures’ and that ‘The UK now has comprehensive tobacco control legislation which is the envy of the world.’

Set against this, however, are some dismal figures:

Over 200 deaths every day are still caused by smoking…8% of 15 year olds…[and] 10% of pregnant women still smoke.

To deal with this dreadful situation, Stevie boldly declares:

Our vision is nothing less than to create a smokefree generation. To do this we need to shift emphasis from action at the national level – legislation and mandation of services to focused, local action, supporting smokers…to quit.

In his visionary enthusiasm he’s even invented a new word, ‘mandation’. I couldn’t find it in any dictionary. Not to worry. Focused, local action to support smokers to quit is the way to go!

I like a man with self-confidence:

…the government will…ensure (sic) that the new legislation is implemented well and that organisations with national responsibilities are joined up (sic)

Now let’s get to the contradictory bit:

Our vision is to create a smokefree generation. We will have achieved this when smoking prevalence is at 5% or below.

Surely a ‘smokefree’ generation means that nobody will smoke, but if up to 5% of the population smokes that’s hardly smoke-free.

The paper also mentions what they call National Ambitions, which include reducing the prevalence of smoking in 15 year olds from 8% to 3% or less, in adults from 15.5% to 12% or less, and in pregnant women from 10.7% to 6% or less, respectively.

It seems to me that if the notion of a ‘smokefree generation’ has any sense at all, then one of the National Ambitions should be reducing the prevalence of smoking for everyone to 0%.

The problem, however, is not with smokers who have quit or people who never start smoking; the problem is with those who don’t quit or who take up smoking ab initio.

Then the vision gets a bit cloudy. They want to:

Help people to quit smoking by permitting innovative technologies that minimise the risk of harm [and] maximise the availability of safer alternatives to smoking.

Why aim so low? If they merely minimise the risk of harm there is still a risk of harm. Why should anyone need ‘safer alternatives to smoking’ when there is a completely safe alternative, namely, not using any tobacco products at all?

As for the laudable aim of getting pregnant women to stop smoking, ‘These [measures] include regularly using Carbon Monoxide (CO) monitors to assess whether [pregnant] women are smoking…’ In other words, they don’t trust them. And these women, unless they opt out, will automatically be referred to stop smoking services through the ingeniously named ‘Saving Babies’ Lives Care Bundle (sic)’.

They really are stuck in discouraging mode:

Tobacco dependence is one of the hardest addictions to break. A smoker will typically have many failed quit attempts before they manage to successfully quit smoking.

Wrong on both counts. If you go about it in the right way it’s easy to stop smoking without using any nicotine products. And the concept of a quit attempt is meaningless – see http://nicotinemonkey.com/?p=683

As for stop smoking services, ‘Smokers who use  them are up to four times as likely to quit successfully as those who choose to quit without help…’ This is misleading because the actual success rate is 20% at best – or an 80% failure rate.

In spite of acknowledging that:

Tobacco is the deadliest commercially available product in England…[and] there is a fundamental and irreconcilable conflict between public health and the interests of the tobacco industry

all that our Steve can offer is a platitude:

The best thing a smoker can do for their health is to quit smoking

It’s clear the government doesn’t really know what to do:

We welcome innovation that will reduce the harms caused by smoking…The government will…continue to evaluate critically the evidence on nicotine delivery products, providing clear communication about what is known and unknown about the short and long term risks of using different products relative to smoking and the absolute risk to children, non-smokers and bystanders.

Perhaps Mr Brine and his colleagues at the Department of Health would allow me to make a suggestion that would, if implemented, solve the smoking problem once and for all.

It should be an explicit government policy to get rid of ‘the deadliest commercially available product in England’ by enacting legislation to phase out and abolish within, say, five years, the manufacture and sale of cigarettes and all other tobacco products.

Text © Gabriel Symonds

How many smoking deaths in the US would be acceptable?

You would think, would you not, that the US Food and Drugs Administration (FDA) Commissioner, Scott Gottlieb, MD, would understand a few basic facts about smoking and nicotine addiction. Yet, although he acknowledges that smoking is a pretty serious problem, causing more than 480,000 deaths in the US every year, in a press release of 28 July 2017 he said he wants to have ‘an appropriate balance between regulation and encouraging development of innovative tobacco products that may be less dangerous than cigarettes.’

Let us dissect this statement. If he wants to ‘regulate’ cigarettes, rather than abolish them, this implies there are some circumstances where smoking is legitimate or acceptable. And what, I wonder, might those be? Then he wants the regulation, such as it may turn out, to encourage the development of new tobacco products that may (or, presumably, may not) be less dangerous than ordinary cancer sticks.

And his idea to achieve this, as he somewhat clumsily puts it, is by:

Envisioning a world where cigarettes would no longer create or sustain addiction, and where adults who still need or want nicotine could get it from alternative and less harmful sources, needs to be the cornerstone of our efforts – and we believe it’s vital that we pursue this common ground.

Now, who are these adults who ‘need or want nicotine’? No one needs nicotine – except those who are addicted to it – and these are the very people who want it for that reason. So what the brave Dr Gottlieb envisages is:

…lowering nicotine levels [in cigarettes which] could decrease the likelihood that future generations become addicted to cigarettes and allow more currently addicted smokers to quit.

Let me lead Dr Gottlieb back to reality. If we wait generations for the decreased likelihood of people being addicted to cigarettes, how many will die from smoking in the meantime? All smokers are currently addicted (to nicotine) – that’s why they smoke. Further, they don’t need to be ‘allowed’ to quit; they just need to quit! And the only thing that will allow the happy state of universal non-smoking to come about within the foreseeable future is to abolish tobacco.

Instead, the envisioning goes on to:

…afford the agency time to explore clear and meaningful measures to make tobacco products less toxic, appealing and addictive.

Presumably it is not their intention to explore unclear and meaningless measures, but this is in effect what all the envisioning will amount to. In any case, I wonder what degree of reduction in toxicity, appealability and addictiveness they have in mind?

Even if such unspecified degrees of reduction in these three attributes were possible, how many people dying in the US every year from tobacco-related diseases would Dr Gottlieb find acceptable? All tobacco products are addictive because they contain nicotine. If the nicotine is somehow reduced so that cigarettes are ‘less addictive’ no one will want to smoke them. Or is that the idea? If so, this would in effect be the same thing as cigarette prohibition. Then why not say so?

Anyway, addiction is addiction; it makes no sense to talk of degrees of addiction. And even if this were true, someone who is deemed to be only lightly addicted may think he doesn’t have a problem and therefore has no need to quit, and someone who is regarded as being heavily addicted may think quitting will be too difficult so she won’t want to try to quit.

We are back to the basic problem: why envisage only reducing tobacco related disease and death rather than abolishing them by abolishing tobacco?

Text © Gabriel Symonds

Out with ASH – in with CAT!

Gentle reader, please bear with me until l come to the bit where I disclose the amazing revelation that recently came upon me in a dream.

Now, the following is from the website of ASH (Action on Smoking and Health), quoting the UK National Institute for Health and Care Excellence (NICE):

While recognizing that quitting smoking is always the best option for smokers, the NICE guidance supports the use of licensed nicotine containing products…to help smokers not currently able to quit to cut down and as a substitute for smoking, where necessary indefinitely.

Unfortunately, this doubtless well-intentioned advice is based on a fundamental misunderstanding of smoking and thus does smokers a disservice.

Here’s why. The talk of ‘smokers not currently able to quit’ fails to recognise that all smokers are unable (or think they’re unable) to quit – that’s why they’re smokers. Further, the qualification ‘currently’ implies smokers may be able to quit at some point in the future, but until they reach that happy state they have tacit official approval to carry on smoking for the time being – which often means a long time.

Today a smoker is unable to quit, but sometime in the future he has a Road to Damascus moment, the scales fall from his eyes and the cigarette from his lips – and suddenly he’s able to quit! So he does. Or does he?

In any case, on what evidence does NICE talk of smokers being ‘unable to quit’? Are there any? It’s indulgent and even collusive with smokers to characterize them in this way. ‘There, there, don’t worry if you can’t quit at the moment – I’m sure you’ll be able to quit sometime in the future!’ This merely gives smokers an excuse and a reason to feel less bad about smoking while they carry on doing it.

Further, NICE really ought to know better than to imply that cutting down the number of cigarettes smoked daily will do any good for a smoker’s health. It won’t. It merely creates a false sense of security: ‘I’m cutting down – so that’s all right then.’

But now we come to the real bummer, if you’ll pardon the Americanism.

NICE seems to think it’s fine for smokers to use, not just any old nicotine products, but licensed nicotine containing products (gum, patches, suppositories, etc.) as a substitute for smoking, where necessary indefinitely’.

You don’t need a substitute for smoking! And, under what circumstances, would NICE be so good as to explain, is it necessary to use licensed nicotine containing products at all, let alone indefinitely.

This nihilistic thinking seems to be, among the NICE people and many involved in so-called tobacco control, that it will never be possible to get all smokers to stop and so the best compromise is that those who can’t or won’t stop should be encouraged to continue their nicotine addiction, where necessary indefinitely, in a possibly safer way than smoking.

ASH’s policy contributes to this weak approach. As mentioned, the acronym means Action on Smoking and Health, but the only action that needs to be taken to deal once and for all with the smoking epidemic, it to abolish tobacco. Unfortunately, ASH doesn’t agree with this.

Therefore, I propose that instead of more and more effort going into ‘tobacco control’, a new organisation – of which I would volunteer to be the honorary secretary and president – should be set up, dedicated to closing down the cigarette factories.

I would call it the Campaign for the Abolition of Tobacco (CAT).

Text © Gabriel Symonds

Why nearly all stop smoking websites are unhelpful

I put ‘How to stop smoking’ in Google and this is what came up (emphases added) :

Readers’ Digest

The 23 Best Ways to Quit Smoking…Make an honest list of all the things you like about smoking…Then make another list of why quitting won’t be easy.

WebMD

So you’re ready to kick the habit. That’s great! Making that commitment is half the battle. It’s not going to be easy. But choosing the best way to quit is a good first step to ensure you stick with it

wikiHow

Nicotine is incredibly addictive and it will take determination to quit….Be prepared for nicotine-withdrawal symptoms…When you stop smoking, you might experience increased cravings, anxiety, depression, headaches, feeling tense or restless, increased appetite and weight gain, and problems concentrating….

helpguide.org

We all know the health risks of smoking, but that doesn’t make it any easier to kick the habit…quitting can be really tough.

kidshealth.org

…it’s true that for most people quitting isn’t easy…Everyone knows it can be hard to stop smoking..the nicotine in cigarettes is a powerfully addictive drug…You’ll need patience and, yes, willpower.

Mayo Clinic

10 ways to resist tobacco cravings…Tobacco cravings can wear you down when you’re trying to quit…tobacco cravings or urges to smoke can be powerful… when a tobacco craving strikes…Try nicotine replacement therapy [or] prescription non-nicotine stop-smoking medications such as bupropion (Zyban) and varenicline (Chantix).

Medical News Today

How to give up smoking: Ten tips…Nicotine in cigarettes is addictive, which is why people experience unpleasant withdrawal symptoms when they try to quit. Nicotine replacement therapy (NRT)…helps to ease some of the symptoms of nicotine withdrawal, such as intense cravings, nausea, tingling of hands and feet, insomnia, mood swings, and difficulty concentrating.

What is noticeable about all these – and they’re a representative sample of a large number of similar sites – is how discouraging they are! They tell you how difficult it will be to give up smoking, the unpleasant withdrawal symptoms and cravings (whatever that means) that would-be quitters will have to face and propose nicotine products (when the smoker is trying to escape from nicotine addiction) or prescription drugs which can only work by causing a chemical imbalance in the brain. No wonder quitting smoking seems to hard!

There is one site which appears fairly high on the list that I haven’t yet mentioned: Allen Carr. This comes nearest to what The Symonds Methods offers and, likewise, recommends no drugs or nicotine products but relies on a psychological approach. Incidentally, Allen Carr died in 2006, ironically from lung cancer, but his method is still available through the business he developed. The problem with it is that although he grasped intuitively why people smoke and therefore realised that a change of mind-set is enough in theory to get smokers to quit, he lacked the necessary medical and biological knowledge to explain clearly the mechanism of addiction, using instead crude similes such as ‘the little monster in your stomach’ and ‘the big monster in your head’.

Does the Allen Carr method work? This begs the question of whether any method of smoking cessation works. Smoking is a voluntary activity. If someone uses the X method and stops for, say, one year, and then a day later starts smoking again, does this mean X method has failed? No, it means the smoker has changed his or her mind about wanting to be a non-smoker. Nonetheless, a study was done in Holland in 2014 (https://doi.org/10.1186/1471-2458-14-952) which, in spite of methodological limitations, showed that in a company setting, 41% of participants were not smoking at thirteen months compared with 10% of controls – a four-fold difference. This is all well and good, but it still means that 59% failed to quit.

We now come to the method I have developed myself, which in all modesty I call The Symonds Method of smoking cessation. In theory, it should be 100% effective. Now hold on Dr Symonds, this is a bit over the top, isn’t it? Actually, no.

When a smoker sits down in front of me to learn how to be a non-smoker again, I ask them to give an undertaking that in the unlikely event they don’t happily stop after the first session, they will come back (without additional charge) for as many sessions as necessary until they do stop. The definition of success, therefore, is someone who doesn’t come back.

I have been accused of being self-serving by saying this, but I think it merely highlights the fundamental problem of smoking: in spite of being well aware of the risks, many smokers don’t want to stop or change to an allegedly safer way of continuing their nicotine addiction.

Text © Gabriel Symonds

The Twelve Worst Ways – and the One Best Way – to Stop Smoking

1. Fear

Horrible pictures on cigarette packs and emphasizing that smoking causes cancer and heart disease assume people smoke because of ignorance of the consequences. This is not so. Everyone these days knows smoking is harmful to health. Scare tactics have relatively little effect because they don’t take into account the main reason people smoke: nicotine addiction, which is so little amenable to logic.

2. Reminding smokers of the benefits of quitting

Reduced health risks, saving money and smelling better (in both senses) are what smokers are already aware of – that’s why they want to quit! So why don’t they?

3. Nicotine patches or gum

If you want to stop smoking you presumably wish to be rid of nicotine once and for all. So what’s the good of putting it into your body by a different route? Nicotine products merely keep the addiction going and make it harder to stop. The poor success rate of around 15% for nicotine patches and gum shows that smokers who quit using these products do so in spite of them, not because of them.

4. So-called Stop Smoking Medicines: bupropion (Zyban) and varenicline (Champix)

These work, if they work at all, by causing a chemical imbalance in the brain. Smokers already have enough of a chemical imbalance in the brain with their nicotine addiction; it makes no sense to increase it with prescription drugs. Many people feel unwell while taking them and a serious (though rare) side-effect is suicidal thoughts.

In any case, using these drugs, as with nicotine products, merely reinforces the fear many smokers have that quitting is too difficult to do on their own. Nothing could be further from the truth!

5. Combining nicotine patches or gum with stop smoking medicine

The same objections as above apply, only more so.

6. E-cigarettes

These are promoted in some quarters as a way to stop smoking. This is disingenuous. They are merely a means of continuing nicotine addiction in a supposedly safer way; it has been claimed that e-cigarettes are 95% safer than ordinary cancer sticks but there’s no proof that this is so. The fact is, no one knows what the effects will be of sucking into your lungs vapourised nicotine together with propylene glycol, glycerin, water and flavourings many times a day, every day for years on end.

Fortunately there is a simple, 100% safe alternative to cigarettes and e-cigarettes: not to use nicotine at all – in any form.

7. ‘Heat-not-burn’ tobacco products, variously called IQOS, iQOS, ‘glo’ and Ploom

It is misleading that these recently released products are presented as a way to stop smoking. They may not be quite as dangerous as inhaling tobacco smoke, but to inhale the fumes derived from heating tobacco without burning it cannot be anything but harmful to health.

8. Humour

There are a number of websites that appear to try to encourage smokers to quit through levity. Smoking is no laughing matter. The apparent difficulty in quitting is not due to lack of a sense of humour. See, for example, my critique of the nonsense put out by healthline.com: http://nicotinemonkey.com/?p=1587

9. Vulgarity

I am not making this up, but there is an NHS-supported website in the city of Leicester in the UK where this is actually their approach. I will not discomfit readers of a sensitive disposition by quoting the words used, but you can read them for yourself if you refer to my blog: http://nicotinemonkey.com/?p=1620

10. Willpower

This means forcing yourself not to do something you have a strong desire to do. Usually it is only a matter of a (short) time before the wish to smoke is greater than the wish to be a non-smoker and willpower loses out.

11. Hypnosis, acupuncture, laser-treatment, supplements and other gimmicks

These methods may work for some people but they are troublesome and time-consuming. If they work, they do so by suggestion. Also, as noted under number 2, they reinforce the wrong idea that quitting is so difficult you need some outside agency to help you.

12. Cold turkey

What does this curious expression mean? It was originally used when someone addicted to hard drugs stopped suddenly and experienced unpleasant or even dangerous withdrawal symptoms including the skin coming out in goosebumps – or should that be turkeybumps?

Many people regard ‘stopping smoking cold turkey’ as the same thing as stopping through willpower. You try to force yourself not to smoke while enduring awful withdrawal symptoms until the desire to smoke goes away. And how long will that take?

And the one best way to stop smoking?

Just stop!

Some smokers may be fortunate enough to wake up one day and say to themselves, ‘That’s it. I’m through with cigarettes.’ And they never smoke again. And they never want to smoke again.

But if you’re reading this blog you’re probably one of the many smokers who genuinely find it hard to stop. Fear not. If you can be helped through The Symonds Method to demonstrate to yourself  why you have continued to smoke in spite of knowing the risks, and why quitting seems so hard, then it will be easy!

Text © Gabriel Symonds

Stopping Smoking through Vulgarity

‘Smokefree’ is a catchy neologism used by the NHS Smokefree campaign. It’s supported by Public Health England which is part of the UK government’s Department of Health. So it’s quite kosher.

But what’s this? The Leicester City Stop Smoking Service at a quick glance looks similar:

As we can see, it offers not just any old licensed products to assist your efforts to become smokefree, but traditional licensed products! Well, bless their cotton socks. The manager, Louise Ross, comments: ‘Every time I see someone vaping I think: that’s another person NOT smoking a cigarette.’

And if the gung-ho Ms Ross were to observe a member of the public going about their business who is neither smoking nor vaping, would she think: ‘That’s another person NOT smoking a cigarette’? It seems to her the normal state of non-smoking is regarded as remarkable and a matter for congratulations.

In either event she seems to have a lot to be pleased about. How does she do it? With vulgarity. I promise I am not making this up. On the redoubtable Leicester City Stop Smoking Service website you soon come across a YouTube video of which the first written words, I blush to tell you, are: ‘Have you got the balls to stop smoking?’ It’s narrated by Gerry Taggart who, you will be glad to know, is a ‘Former Northern Island and Leicester City Defender’ – and I hasten to add he speaks like the gentleman he is throughout the short film. However, there is even a page labelled ‘Balls to stop’. It seems this website caters only to men. Incidentally, Gerry Taggart tells us he just woke up one day and decided he didn’t want to smoke any more – and he hasn’t. Once he put his mind to it, it was easy – and he didn’t need e-cigarettes.

Leaving aside for the moment the question of why you should need any sort of product to stop smoking, let us look at this stop smoking service’s wording in a little more detail:

We offer all the traditional licensed products (patches, mouth-spray, inhalators, Champix and many more), and advisors are skilled in helping people choose the right product for them.

Presumably the products don’t include e-cigarettes because these are not licensed for smoking cessation.

But they are included – very much so. The service emphasizes that it’s ‘ecig friendly’. That’s rather obvious: almost every page of the website shows pictures of e-cigarettes or contains articles about vaping.

If you want to stop smoking, or as one might say, be smoke-free, this conjures up a picture of giving up smoking and thereafter carrying on with your life without the need to poison yourself all the time by sucking tobacco smoke into your lungs.

But with these sorts of stop smoking services it must be rather disappointing for potential clients. The message is that in order to return to the normal state of being a non-smoker, they will instead of smoking be encouraged to put relatively pure nicotine into their bodies by other means and this could go on indefinitely. Or they may be offered a chemical drug to take for weeks or months. Or maybe clients will be offered nicotine products and chemical drugs.

On the other hand, rather than using a product to stop smoking, one could approach it in a different way that might be expressed by paraphrasing Ms Ross: ‘Every time I see someone vaping I think: that’s another person in the thrall of NICOTINE ADDICTION!’

Surely, someone who wants to stop smoking wishes to be free of nicotine in any shape or form. In this case, is so-called nicotine replacement the best that can be offered, or is it just second best? Why should anyone have to settle for second best? The fact that smoking substitutes are offered at all merely reinforces the fear that smokers already suffer: the prospect of never smoking again is almost too much to contemplate.

You don’t need ‘products’, let along nicotine-containing ones, to stop smoking. You just need to understand why you’re in such a pickle in the first place. Or, as shown by Gerry Taggart, you need a different mind-set. Then quitting is easy.

Text © Gabriel Symonds

Up the Garden Path to Prove the Useless about E-cigarettes

 

Why not just eat a banana?

The latest breakthrough since lunchtime, if you’ll pardon the cliché, is revealed in the result of a study carried out at Penn State College in the US, styled Population Assessment of Tobacco and Health (PATH). Did they think of the acronym first and then juggle the words to find a match? (Report in Penn State News, 17 June 2017.)

It was another questionnaire type of study. Out of 32,320 people who responded to a survey, only 3,586 were found to fit the study criteria. The subjects were cigarette smokers and e-cigarette users. Or cigarette users and e-cigarette smokers.

Where did the PATH lead to? Let’s hear it from lead author Guodong Liu, assistant professor of Public Health Sciences at Penn State: ‘The findings indicated that e-cigarette users were relatively less dependent than cigarette users.’ Amazing! Putting it another way, he said: ‘No doubt about it, e-cigarettes are addictive, but not at the same level as traditional cigarettes.’ Well, fancy that.

How did they determine that vapers were less addicted than smokers? Like this:

Compared with cigarette smokers, e-cigarette users waited longer to start using their product after waking up. Vapers were less likely to consider themselves addicted, to have strong cravings or to feel like they really needed their product. They were also less likely to say they found it difficult to refrain from using their product in restricted places.

Very interesting, but so what? The reality for both smokers and vapers is that they ‘use’ their ‘product’ many times a day, every day, for years on end and find it difficult to stop. Ergo, both types of nicotine user are addicted. It matters not one jot or tittle whether someone is more, or less, addicted and the very notion of degrees of addiction, being based on the above-mentioned arbitrary criteria or in any other way that might be thought up, is groundless as well as pointless; either someone is addicted or they are not.

But wait – there’s more! ‘Planned follow-up studies will help determine if e-cigarettes could lead to traditional cigarettes dependence in the future’, says Professor Liu. The experimenters apparently see a need for these follow-up studies because, we are informed, ‘experts have raised concerns that e-cigarette use could cause nicotine dependence and lead to cigarette use, reversing hard-won public health gains.’

What is it with these so-called experts, and who are they anyway? Of course e-cigarette use causes nicotine dependence. Even Professor Liu recognises that. One might as well ask whether cigarette use causes and sustains nicotine dependence. (Dependence sounds nicer than addiction, doesn’t it.) Why else would anyone in their right mind want to suck chemical-laden fumes into their lungs all the time?

Eventually we come to the reason for the huge effort that went into the study:

The PATH study findings are expected to inform future tightening or loosening of regulations around vaping products. In May 2016, the US Food and Drug Administration began regulating e-cigarettes, ruling that they could not be marketed or sold to minors under eighteen years old.

That brings me to another point. Why is it that the regulations, with whatever degree of tightening or loosening is thought appropriate, are intended to shield only minors from the marketing or selling (what’s the difference?) of e-cigarettes? What about older people? Don’t they count?

Everyone needs to be shielded from the marketing or selling of an addictive drug delivery system (the cigarette) that kills seven million people every year worldwide (WHO figure).

But whether or not using e-cigarettes leads to people taking up smoking who otherwise wouldn’t, we still have the same problem: the continuing marketing and selling of ordinary cancer sticks.

If conventional cigarettes were no longer available – through being banned – the problem of whether e-cigarette use leads to smoking would be purely academic. And if e-cigarettes are indeed so much safer than conventional cigarettes – putting aside the question of why anyone in their right mind would want to use nicotine at all – then that would be a real gain for public health.

That is, as long as nothing bad will happen to you from sucking e-cigarette fumes into your lungs a hundred times a day, every day, for twenty years.

Text © Gabriel Symonds

Cancer Research UK’s failure to call for banning cigarettes

 

Why is this allowed?

As an example of the continuing official confusion in about smoking/vaping, here is a statement (9 Dec 2016) by Cancer research UK:

Harm reduction is a type of public health policy that aims to reduce the harmful consequences of substances, or actions, without necessarily reducing or eliminating the use itself. For example, condoms don’t completely eliminate the risk of sexually transmitted infections, but they reduce the risk of contracting one by about 99%. Same goes for seat belts and airbags in car accidents.

This is a false analogy. What they say about condoms, seat belts and airbags is true, but whereas sex and car transportation are normal or essential human activities, smoking is not a normal or essential human activity; it is drug addiction. And why do they say, in relation to the harmful consequences of substances, which must include smoking, ‘without necessarily reducing or eliminating the use itself’. Surely this is the whole point. Even if we allow that including the word ‘reducing’ here was unintended, and we have, then, ‘without necessarily eliminating the use itself’, why is Cancer Research UK apparently not concerned about eliminating ‘the use’, that is, smoking itself?

Again, they patronisingly say, ‘E-cigarettes aren’t 100% safe. But very few of the things we do each day, or the products we buy, carry no risk at all.’ This is the same false analogy in different words. Using e-cigarettes – an unnecessary and pointless substance addiction – cannot be compared with ‘the things we do each day, or the products we buy [in the course of normal human activities]’.

The conclusion is: ‘The evidence is showing e-cigarettes can help beat the tobacco epidemic. And when they have the potential to save millions of lives, should we just sit back and wait?’

Of course we should not just sit back and wait. But if they are so confident that the evidence shows e-cigarettes can help to beat the tobacco epidemic and have the potential to save millions of lives, why has it apparently not occurred to them that tobacco should be banned at the same time?

Note the emotional appeal: ‘save millions of lives’. It is not as if we are talking about  normal unavoidable risks, such as riding in motor cars or using ladders to change light bulbs. Smoking is a voluntary activity and the millions of lives that are at risk from this cause could be saved by smokers merely ceasing to smoke. So if Cancer Research UK believes the way to do this is for smokers to change their way of obtaining nicotine to e-cigarettes, it implies that they think nicotine addiction in some form or other is part of normal human life.

Another view of the unnecessary and pointless difficulties that are unwittingly put in the way of people wishing to stop smoking, in spite of the best intentions of stop smoking counsellors, is shown in a film put out by Cancer research UK, called ‘Trying to stop smoking – Brian’s story’.

Here, in the first word of the very title of the film, ‘Trying’, we have a spotlight on the wrong-headed orthodox approach to smoking cessation. I have argued before there is no such thing as trying to stop smoking; there is only failing to stop. See, for example, these blogs:

http://nicotinemonkey.com/?p=1435 and  http://nicotinemonkey.com/?p=683.

Brian tells us he’s forty-nine years old and has been smoking for about thirty years. He wants to stop because he’s afraid of dying prematurely. What stronger reason to quit could one possibly have? He’s tried (that is, failed) to quit about four times, but he just gave in, he says. Now he’s decided to access his local stop smoking service. They provide support from a trained advisor. So far so good. But now ‘[the clients] get their choice of stop smoking medication.’ Already we have reinforcement of the difficulties of stopping: it’s so hard to quit you need a drug to help you, for goodness’ sake! He’s going to take a drug called Champix which ‘blocks the nicotine receptors in the brain’. So there should be no problem then? Brian says, ‘Tomorrow’s the quit date. I shall have my last cigarette. The Champix – I’ve been on it six or seven days now, you can really feel it working – I feel ill.’  This is actually what he says.

Then the following encouraging words appear on the film: ‘The stop smoking services give you the best chance of stopping smoking, but it’s still hard and only half of people succeed.’ Brian continues: ‘When I woke up this morning I really, really needed a cigarette, but after a while I just forgot about it.’ Yes, that’s the point: if you have the right attitude you can just forget about smoking – without the need to feel ill from Champix. Then he has the carbon monoxide level in his breath measured – and it had gone right down after one day of not smoking. Wonderful – if entirely predictable. Next, he tells us he’s feeling ‘Kind of rough. Absolutely dying for a (expletive deleted) cigarette…is it working? No…The last four weeks have been pretty stressful.’ Nonetheless, his final words are that the counselling and the drug have ‘given me an extra chance…I feel good…Yeah.’ Let’s wish him luck to resist any temptation to smoke again.

Now, consider Brian’s struggle to give up smoking and his taking of a drug that made him feel ill to achieve this aim, to say nothing of the possible harm he has already done to himself by smoking for thirty years: what more does Cancer Research UK need to call for an outright ban on tobacco?

Text © Gabriel Symonds

Exploding e-cigarettes

Why bother with all this?

The doughty online publication, ASH (Action on Smoking and Health) Daily News, on 9 June 2017 carried a warning headline: ‘Safety advice given after e-cigarette fire’.

A woman called Leanne Williams had a potentially serious problem with an ‘88 Vape’ brand e-cigarette apparatus.

This is how 88 Vape advertises these contraptions on their website:

Here at 88 Vape we have two priorities: unrivaled pricing and high quality…Being such exceptional value for money is crucial to 88 Vape. We believe it gives everyone the taste of vaping freedom without compromising on flavour, quality and variety!

We have carefully selected the 15 most popular e-liquids so that you can find a delicious flavour to enjoy! Whether you choose our traditional tobacco blend, Rolling Leaf, or our wonderfully sweet Morello Cherry your vape will be bursting full of flavour!…Switch to 88 Vape today and you’ll never look back(Buzz-words and clichés emphasised.)

Also, note this:

Electronic Cigarettes are now one of the largest global markets worth an astounding £1.8 billion

Gentle reader, please keep this in mind as I warm to my theme.

The unfortunate Ms Williams takes up the story:

It was on charge on the landing. I heard a big bang, and my other half jumped out of bed. It was in flames and there were burns all over because it had blown up and the bits were also on fire. If anyone had been near it, it would have really hurt them.

A lucky escape. But Ms Williams didn’t want to let it go at that. She complained to the store from which she had bought her 88 Vape device, B & M Bargains in Standishgate. They responded:

The packaging on the item states it should be charged with a USB port and not using a wall charger as you have done. Due to this, we can confirm the product is not defective and the issue has been caused due to improper use.

Unfortunately, some people have actually been hurt by these kinds of accidents:

In October 2014, a man was rushed to hospital with horrific injuries after his e-cigarette exploded. The man in his forties was found seriously injured in his house in Scholes after the e-cig blast caused shards of metal to embed his legs. The explosion was so powerful that it even blew out the lenses in his glasses. He had thrown the brand-new e-cigarette on the floor after it suddenly became very hot, before it exploded and sent pieces of metal flying into the man’s legs

Now note this:

One of the man’s neighbours, Billy Baldwin, said he was shocked to think that such a small device designed to help you could cause so much injury. (Emphasis added.)

These devices are not designed to help the purchasers. They are designed to help the bank balances of the manufactures and sellers.

At least 88 Vape makes one thing clear: ‘Please note that 88 Vape products have not been designed to be a Nicotine Replacement Therapy.’

The implication, nonetheless, is that for people who believe they cannot stop putting nicotine into their bodies, these products are safer than smoking cigarettes.

This defeatist attitude is encouraged by conventional stop smoking counsellors: stopping smoking is too difficult, so the next best thing it to continue your addiction in a supposedly safer way. This only encourages smokers (synonym: nicotine addicts) in their belief that stopping smoking is, indeed, too difficult for them. Good! It’s officially sanctioned that continued nicotine use is OK!

So, e-cigarettes – provided you can avoid them blowing up and causing injuries, and if you want to go to the expense of buying a starter kit and the bother of plugging them in with a USB connection to re-charge them and then keep buying the e-liquid to generate the vapour – are a great way to increase the £1.8 billion market!

The problem can be seen from another perspective. This is a conversation I sometimes have with smokers who come to see me for an unrelated medical problem.  (Dr = doctor; Pt = patient.)

Dr:  If there were an easy way to stop smoking would you be interested?

Pt:  Yes, of course I would.

Dr:  All right, please make an appointment and I guarantee you will quit without difficulty.

Pt: I’ll think about it.

The dilemma this puts smokers in is well summed up by one patient who said to me: ‘Thank you very much, Dr Symonds, but I don’t want to come for your smoking cessation method because, if I did, I’m afraid I would succeed!

Text © Gabriel Symonds

Vaping Forever!

Here is a fantastic piece of news about an undercover investigation by the Royal Society of Public Health, reported in April 2017. They found that nine out of ten retailers of e-cigarettes ‘are turning a blind eye to their use by non-smokers, and effectively pushing them as a lifestyle product.’ Very wicked!

What are vape shop staff supposed to do when a customer comes in who wants to buy this type of nicotine delivery device? Ask the customer to prove he or she is a smoker? Or say, ‘I’m sorry, I can’t sell e-cigarettes as a lifestyle product – you’ll have to become a smoker first, so when you’ve got a nice smoker’s cough and nicotine-stained fingers come back and I’ll sell you e-cigarettes to help you stop smoking!’?

Shops exist to sell their goods. Quite rightly there are age-related restrictions on alcohol and tobacco, but it’s one thing to ask a potential customer to prove his or her age and quite another to prove that they’re smokers. And why should the proprietors of vape shops be put in this invidious position? The Independent British Vape Trade Association, as it’s known, tries a bit of awkward fence sitting in its Code of Conduct, including the admonition, ‘Never knowingly market to anyone who is not a current or former smoker, or a current vaper.’ Anyone can say they are a former smoker, and I don’t blame them for casting the net a bit wide.

The government should make up its mind about how e-cigarettes and other nicotine delivery devices, and indeed ordinary cigarettes, should be regulated.

If e-cigarettes are supposed to be used only by smokers as an aid to quitting then they’ll have to be sold under licence or with a doctor’s prescription. But how long will this be for? Presumably, as long as it’s deemed necessary for the smoker to be cured of the desire to smoke cigarettes. And how long will that be?

The problem is in the concept itself of regulation of e-cigarettes. Regulation implies that nicotine use by some people under some circumstances is legitimate or appropriate. For example, e-cigarettes should be allowed to be sold to adult smokers as an aid to smoking cessation. But before starting to deal with the almost impossible practical problems of restricting sales to this group, one fact needs to be understood: the only reason people use nicotine at all is because of their perceived inability to stop.

I experienced an example of this the other day when I had occasion to ride in a taxi in Tokyo. It was raining and I hailed a taxi stopped at traffic lights. All the windows were open in spite of the rain. I got into the taxi and then realised why this was – there was a strong smell of tobacco. Smoking is not permitted in taxis but the driver explained: the previous passenger (or ‘honourable guest’ in the Japanese language) who had just got out, had been using a new nicotine delivery device with the unpronounceable name of ‘Iqos’ which has just been released in Japan.

This contraption, according to its promotional site, is ‘a smokeless cigarette that…uses real tobacco refills, but instead of burning it to produce hazardous smoke and tar, it heats it to produce tobacco-flavored vapor.’ So that’s all right then.

Incidentally, I have never understood how tobacco smoke or a vapour has a taste but it certainly has a smell – or rather, I should say, it stinks. As it was raining I resisted my impulse to get straight out of the taxi, and the stink gradually dissipated. Clearly, legislation on smoking hasn’t yet caught up with modern marketing developments.

There is already enough trouble with cigarettes. We don’t need new nicotine delivery devices. It is misleading that e-cigarettes or ‘heat-not-burn’ tobacco products such as Iqos should be promoted as ways to stop smoking: they are merely new – and potentially hugely profitable – ways of changing one way of feeding a smoker’s nicotine addiction for another.

Text © Gabriel Symonds

Over 600 Flavours!

The UK Ecig Store likes to make a splash: they boast of ‘Over 600 e-cigarette flavours’!

So much for e-cigarette regulation in Britain. If this sort of advertising is not to entice young people to ‘vape’ and get hooked on it I don’t know what is.

Now let’s go to the small print at the bottom of the opening page of their website

Electronic cigarettes are not suitable for use by…persons who should avoid using tobacco or nicotine products for medical reasons

If we remove the redundant words we have: ‘Electronic cigarettes are not suitable for persons who should avoid using them for medical reasons.’ But everyone should avoid them for medical reasons! E-cigarette vapour contains potentially harmful substances and the risks of long-term use are unknown. Therefore the UK Ecig Store should not be selling these products. Nor should anyone else.

Obviously, if someone has a heart or lung condition it would be particularly inadvisable for them to smoke, but these are just the people who, if they felt they could not cope without nicotine in some form, might be advised to use e-cigarettes instead of smoking. Not by me I hasten to add – I would offer to cure them of nicotine addiction in any form.

So the good old UK Ecig store is really contradicting itself or shooting itself in the foot by saying, in effect, that no one, because of medical reasons, should use e-cigarettes and the sooner they shut up shop the better.

Nonetheless, some doctors actively promote e-cigarettes as a new way to stop smoking!

There is something odd about this. E-cigarettes are not being promoted as a stop-smoking aid in the same way as other methods – nicotine gum or patches, prescription drugs, a course of acupuncture or some other gimmick. With these methods, or ‘tools’ as they are sometimes called (why should you need a ‘tool’ to stop smoking?), obviously the idea is that you use the gum or patches or take the drug or whatever it is for a limited time and then with reasonable luck you will have stopped smoking and will never want to do it again. Incidentally, how many people succeed with this kind of approach? At best it’s around the not brilliant figure of 20%.

Underlying the reason for the poor results of these methods is the assumption that you need a way, method, technique, system or ‘tool’ to stop doing something. Why not just stop? And if just stopping seems difficult or even out of the question, then one should ask why should it appear to be difficult, or very difficult, to stop?

It’s not as if you are on a bicycle with defective brakes going downhill: you want to stop but even pulling hard on the brakes doesn’t impede the bicycle’s progress very much. In such a case one could talk of trying to stop to avoid a crash at the bottom of the road.

So there must be some reasons for the alleged difficulty in stopping smoking. Three possibilities come to mind. Either the smoker, in spite of what she might say, doesn’t really want to stop and only says she does to appease the naggers or the doubts in her own mind.

Or there may be a genuine difficulty in refraining from picking up the next cigarette, putting one end in your mouth, setting fire to the other end and sucking the fumes thereof into your lungs.

A further possible reason that may be suggested for difficulty in quitting is that the smoker perceives some benefit or enjoyment from smoking that is so alluring he doesn’t want to give it up, but this is just another way of saying he doesn’t want to quit. Even so, a little thought and discussion will show that the idea of the pleasurable or helpful cigarette is illusory.

E-cigarettes are not promoted as a means of stopping smoking similarly to other cessation aids, but as a replacement for smoking that is often used long term. Therefore there is something underhand about promoting e-cigarettes as a smoking cessation aid. All that e-cigarettes achieve is to allow a smoker to continue her nicotine addiction in a supposedly safer way.

Nonetheless, promoted they are (except in a few countries that have banned them). You can see why this is: e-cigarettes are being endorsed and encouraged as alternatives to smoking because this is a multi-billion dollar industry. That is why every man and his dog in the nicotine business are plugging e-cigarettes for all they are worth. Customers are being lured with a promise of wonderful flavours – like cherry, apple or banana.

But if you really want to experience the joys of these flavours all you have to do is to eat a cherry, apple or banana!

Text © Gabriel Symonds

The Rubbish Way to Stop Smoking

If you were new to the piano and wanted to play Bach’s C major prelude you would need to practise. (There are a number of YouTube videos showing how to do this.) But if you decided to give up learning this wonderful piece – which would be a pity – all you would have to do is close the piano and walk away; there would be no ‘trying’ about it. It would be nonsense to talk of failing to stop playing the piano.

On the other hand, in relation to cigarettes, the concepts of ‘trying’ and ‘failing’ to stop smoking feature a great deal.

Dr Colin Mendelsohn, a ‘tobacco treatment specialist’ as he mysteriously calls himself (http://nicotinemonkey.com/?p=675), might be said to represent the mainstream medical approach to the smoking problem. He has set out his philosophy, or credo, in a published paper (Medicine Today 2011; 12(10): 35-40).

This paper is contentious from the first sentence:

Most smokers repeatedly fail to quit because they are addicted to nicotine and have lost control of their smoking behaviour.

This is either a tautology (they are addicted and have lost control of their smoking behaviour) or he implies that some people, in spite of being addicted to nicotine, are nonetheless in control of their smoking behaviour – a contradiction in terms.

The meaning of the opening phrase, ‘repeatedly fail to quit’, is obscure – or it could be taken as the defining characteristic of all smokers who repeatedly fail to quit all the time. Each cigarette stubbed out could be viewed as a quit attempt, but the attempt fails because it’s followed by another cigarette.

On his website (http://colinmendelsohn.com.au/posts/cold-turkey-effective-way-quit-smoking/) Dr Mendelsohn says:

We often hear that many smokers quit ‘cold turkey’ (without professional advice or support) and that this must therefore be the most effective way to quit. Of course this is rubbish! Research clearly shows that using willpower alone is the least successful method for quitting smoking. (Emphasis added.)

In support of the last sentence he cites a paper in the journal Nicotine and Tobacco Research (https://doi.org/10.1093/ntr/nts164) with the presumably humorous title, ‘The Most “Successful” Method for Failing to Quit Smoking is Unassisted Cessation’. The three authors of this paper, one of whom is the self-styled world expert on smoking and addiction, Professor Robert West, take issue with the claim that ‘unaided quit attempts are effective because many former smokers report to have quit without help’, adding that ‘This argument is based on a logical fallacy, which ought to be obvious, but clearly it is not.’

They then try to explain what they mean by this curious last sentence:

…the most popular method used by people who failed to quit smoking was unassisted cessation. To put it another way, the ‘most successful’ method for failing to quit smoking is to use willpower alone. What does this tell us about the best way to try to quit? Nothing.

The charge of logical fallaciousness applies to these authors rather than to those who conclude that their research shows unassisted quitting is the best way to stop smoking. Here’s why: to talk of a ‘method’ of failing to stop doing something is meaningless – you simply carry on doing whatever it was. Also, on what grounds do they assume that the alternative to assisted cessation is willpower? What about smokers who just get fed up with smoking and decide they are not going to do it anymore? You don’t need willpower to refrain from something you don’t want to do!

They continue:

The problem…is that effectiveness cannot be inferred from the number of individuals using a specific method to achieve a goal only amongst those who have already achieved that goal.

But this is just what can be inferred from taking a random sample of former smokers and asking how they stopped. In a paper of the sort so condescendingly criticised by the world expert on smoking and addiction and his colleagues, there appears this encouraging conclusion:

Research shows that two-thirds to three-quarters of ex-smokers stop unaided.

(Interested readers can find it at http://dx.doi.org/10.1371/journal.pmed.1000216. It’s called The Global Research Neglect of Unassisted Smoking Cessation: Causes and Consequences by Simon Chapman and Ross MacKenzie, February 2010.)

The concept of a ‘quit attempt’ is hollow and pointless. If a smoker has stopped smoking and has no intention of starting again, that is someone who has successfully quit – not someone who has made a successful quit attempt. Even the word ‘successful’ in this context is redundant. If we allow it, however, then what is an unsuccessful attempt? The idea of attempting to stop smoking is an excuse that the smoker has handed to him on an plate, or rather on an ashtray, to indulge his unwillingness to quit: he’s trying, so that’s all right then. And in the meantime – which often means a long time – he carries on smoking!

Our world expert mentioned above even goes so far as to say in a book he wrote (see review http://nicotinemonkey.com/?p=75) that if you don’t stop smoking ‘you have not failed – there is no such thing as failure when it comes to trying to stop smoking.’ Really? All smokers could be considered as having failed to stop. Similarly, we could well say there is no such thing as ‘trying to stop smoking’. Those who stop, have stopped; those who are trying to stop, smoke.

If the experts don’t like this way of looking at it, would they please tell me what is the definition of a quit attempt? Is it the same as not smoking for a certain length of time? If so, how long and why? Such a criterion would be arbitrary. Suppose a smoker has ‘attempted’ to quit and manages not to smoke for a year, but the next day she starts smoking again. Does this mean the attempt has failed? Using the length of time of non-smoking as the criterion for successful quitting, therefore, means one would have to follow-up ex-smokers until they died, but this would be rather impractical.

I have pointed out before that when smokers say they are trying to quit, this is not the expression of a wish to stop smoking, but a statement of their intention to continue.

Therefore the concept of a ‘quit attempt’ in relation to smoking is unhelpful and should be abandoned.

Text © Gabriel Symonds

Vaper’s lung – the disease that will never be, I hope

There was an interesting article two days ago in the online Manawatu Standard titled: ‘Government legalises e-cigarettes in effort to make New Zealand smokefree by 2025.’

Why 2025? Because this is a nice round figure? Why not sooner, say 2019? Apart from the date by which the New Zealand government is trying to achieve this noble goal, it’s planning to do it, not in the obvious way by banning tobacco, but by legalising e-cigarettes.

What the New Zealand government hopes will happen, it seems, is that smokers will give up smoking or, if people haven’t yet started to smoke, they won’t, and, as a substitute for inhaling tobacco fumes, everybody who is desirous of ‘using’ nicotine will from 2025 do it with e-cigarettes instead.

The thinking goes that to save lives what is needed is a safe, or at any rate a safer, way of taking nicotine into your body. And keep taking nicotine into your body. Like many times a day, every day for years on end. Because this is what vapers, as they are known, do, or what a large number of them do.

A link from the venerable Manawatu Standard’s page leads to another site (stuff.co.nz) from a year ago where the questions ‘How safe are e-cigarettes and can they really help someone quit smoking?’ are posed and then answered thus:

Long-term safety studies are needed, but [this]…will take decades, during which time there is the potential for many thousands of smokers to be deterred from trying something that might help them to quit.

Why do they write as if nicotine in some form or other is a normal consumer product which it would be a hardship to do without? Why does anyone in their right mind need to use nicotine at all? Will somebody please tell me.

If smokers want to quit, why don’t they just quit? Why do they need ‘something that might help them’ to do this? Why is it implied that smokers are helplessly in the grip of their addiction and can’t do anything about it except grasp at straws?

The article continues:

If e-cigarettes are genuinely going to have a chance at replacing tobacco smoking, they need to provide nicotine in a similar way to regular cigarettes.

Why does tobacco smoking need to be replaced? Whence comes the idea that smokers are in the infantile position of being incapable of quitting unless they have an alternative to or substitute for regular cigarettes? What about not smoking and not using nicotine at all?

Could one of the reasons that smokers seem to find it so hard to quit be because articles like these encourage them in such a belief?

The same concern is expressed from Australia by Dr Colin Mendelsohn – about whom I’ll have more to say in a later post – who thinks smokers should be treated with nicotine before they even try to quit (‘pre-quit’).

Dr Mendelsohn laments that ‘the Australian Therapeutic Goods Administration’s recent interim decision (it has since been confirmed) to effectively ban nicotine-containing e-cigarettes is a harsh blow to smokers,’ and that ‘Australian smokers will be denied access to life-saving technology estimated to have helped millions of smokers to quit overseas.’

If smokers whose lives are in danger from smoking want to avoid dying from this cause, all they have to do is to stop smoking (unless they’ve left it too late). Why does Dr Mendelsohn apparently think so many smokers are incapable of quitting unless they use more nicotine?

It’s not as if e-cigarettes are used for some weeks or months as a treatment for smoking and when a cure is achieved the e-cigarettes are abandoned. What happens with many smokers is that they switch to e-cigarettes and continue their nicotine addiction in this way indefinitely.

E-cigarettes do not only contain nicotine. They also contain propylene glycol, flavourings, tobacco-specific nitrosamines, carbonyl compounds, trace amounts of metals, volatile organic compounds and phenolic compounds. Many of these are potentially poisonous. The effects of inhaling such substances in e-cigarette vapour repeatedly every day for years or decades are unknown but it would not be surprising if vaping were to be found to cause serious lung, heart and other health problems. I hope that a disease that might be called vaper’s lung will never occur – but it could.

To allow this e-cigarette experiment to be foisted on the public is not only unnecessary but also irresponsible.

Text © Gabriel Symonds

Are smokers getting a raw deal?

Tobacco is not an illegal substance yet the government is persecuting a minority. I think that’s a disgrace in a social democracy.

Sir Ronald Harwood
Playwright and screenwriter

There is in Britain a smokers’ rights group called Forest (Freedom Organisation for the Right to Enjoy Smoking Tobacco). The name tells you a lot. But are there people who want to be free to smoke tobacco even if they don’t enjoy it?

Forest paid for a survey to be carried out by the Centre of Substance Use Research. The subsequent report, published in December 2016, had the title and subtitle, ‘The Pleasure of Smoking’ and ‘The Views of Confirmed Smokers’, respectively.

It’s rather a good report and I’m glad I discovered it for the insight it gives into what’s going on in some smokers’ minds.

The problem, the report says, is that over the last thirty years tobacco control measures have changed smoking from ‘being a popular, socially accepted behaviour to…an anti-social, health harming, stigmatised behaviour [and that] smokers…have become increasingly marginalised.’

There is a difficulty here, it seems to me, in referring to smoking as a behaviour. I suppose this word is used in the sense of the way in which one acts or conducts oneself. I am not just being pedantic (although I am sometimes accused of pedantry), because the whole argument hangs on this word. As readers of my blog will be aware, I would characterise the activity of smoking as drug (nicotine) addiction rather than just a behaviour that one may engage in or not.

In a brief correspondence the first-named author of the report made the point that:

[T]o explain or reframe [smokers’] accounts of their pleasures [in terms of relieving nicotine withdrawal symptoms] seems to me to largely constitute the imposition of one interpretive frame (nicotine dependence) upon the views of smokers…many smokers did indeed perceive smoking as being pleasurable in ways other than having to do with the satisfaction of any nicotine dependence. (Emphasis added.)

 I’ll come back to this is a moment.

They surveyed 650 smokers who responded to an online questionnaire. Admittedly they were a self-selected group rather than a representative sample, but this didn’t matter for the purpose of the research. A significant finding was that ‘Nearly all participants (95%) cited enjoyment as their reason for smoking’ although ‘Over half (56%) of those surveyed said that they felt they were addicted to smoking.’

This implies there is such a state as an enjoyable addiction. Or is this a contradiction in terms?

Furthermore, ‘The majority of the smokers surveyed felt they were treated very unfairly (77%) or quite unfairly (14%) by government.’ I think they have a point. There is blatant inconsistency in the government’s attitude: cigarettes are on open sale, yet smoking is characterised as anti-social and disease-causing.

The claim of enjoyment as a reason for smoking is a recurring theme in the report. Smokers seemed well aware of the risks but nonetheless apparently decided to continue to smoke. Hence ‘many smokers themselves saw their smoking as a source of pleasure, a choice rather than an addiction.’ This is cited as one of the reasons that alternatives to smoking, particularly e-cigarettes, were not rated highly: they didn’t provide the same pleasure as ordinary cigarettes.

There are two assumptions that smokers and those in the tobacco control movement make. One is that smoking really is pleasurable, and secondly that if smokers are going to be persuaded to stop they will need a substitute for combustible cigarettes which will provide the same or a similar pleasure as smoking.

Both these assumptions are questionable.

First of all, what do smokers mean when they talk of the pleasure of smoking? And if we take them at their word, is this so great or important that it explains why they have a compulsion to do it twenty times a day, every day. Do they say, or think, forty minutes after smoking a cigarette, ‘By golly, that was marvellous! I must have another one!’?

It’s a strange kind of pleasure. There are many things I find pleasurable, for example eating chocolates. But I don’t eat chocolates every day and I certainly wouldn’t want to eat twenty in one day – I’d feel pretty awful if I did.

It’s also interesting that many smokers in the survey had withering criticisms of smoking cessation services and made the valid point that:

[I]f stop smoking services are going to succeed…they are going to have to be prepared to engage with smokers on the terms upon which those individuals view their own behaviour. This includes being willing to recognise the pleasurable elements of smoking.

This comes back to the question of whether smoking really is pleasurable. If one engages with and encourages smokers to say what, exactly, is pleasurable about it, we don’t get very far. Is it the smell? The taste? The sensation of the smoke going into your lungs? Do you experience some real pleasure every time you take a drag? It will soon become clear this doesn’t make sense. What other activity do you feel compelled to engage in twenty times (or more or fewer) every day and feel a rising panic if you’re not allowed to? With a little open-minded discussion, the reality soon emerges that in the normal sense of the word smoking is not pleasurable. Many smokers actually dislike smoking and wish they didn’t have to do it. Smoking seems pleasurable only because it gives temporary relief to the discomfort the smoker was in before he or she lit the next cigarette.

Some comments about the supposed enjoyment of smoking are very sad: ‘I enjoy smoking and there is very little in life that is enjoyable.’ ‘I suffer from lifelong depression and a sense of inadequacy. Smoking is the only thing that gets me through…smoking is my great source of comfort and peace. Without it there would be nothing.’ ‘My life has been difficult. Smoking has helped me survive.’

These unfortunate people clearly have serious problems. But rather than the methods currently being offered by stop smoking services, a different approach could be tried: they could be helped to demonstrate to themselves that, rather than their lives being almost unbearable without smoking, if they could recover from the drugged state that smoking induces, they would feel much better without smoking.

Text © Gabriel Symonds

Vaping for Fun

Smoking used to have a certain image. When Sherlock Holmes had a difficult crime problem to solve he would smoke shag tobacco in his pipe and think it through. He also used cocaine and morphine to escape from ‘the dull routine of existence’ as he put it. The creator of Holmes, Sir Arthur Conan Doyle, died in 1930, long before the dangers of smoking were recognised.

I used to smoke a pipe myself – a Petersen pipe – because I thought it looked impressive. And in the 1970s for a time I worked for Dr Peter Abbott. He discovered in the Sudan in 1956 the cause of a terrible disorder called Madura foot – a fungus infection. He used to smoke a pipe and grew his own tobacco in his garden, though he recognised he was addicted to it.

I remember a patient, a professional photographer, who used in his own publicity a photo of himself with his arms folded over his Hasselblad camera on a tripod. He was a smoker and said smoking was part of his image. Nonetheless, he agreed it wouldn’t look very appealing if his promotional material showed him with a cigarette in his mouth.

Times have moved on and the only image that smoking now has is an undesirable one. The prevalence of smoking is going down in most developed countries but the number of e-cigarette users is increasing: there are nearly three million in the UK.

And not just in the UK. The other day in my local neighbourhood in Setagaya-ku in Tokyo I noticed a young man walking along the road holding in one hand a metallic tube-like object. At irregular though frequent intervals he would discretely put one end of it into his mouth – and suck. This would be followed by the expulsion of a brief puff of mist into the air. Then I realised he was a ‘vaper’ (vapeur if you’re French) and what he was doing was inhaling into his lungs nicotine-laden fumes generated by his e-cigarette.

Most people who vape do it as an alternative to poisoning themselves with tobacco smoke – which they previously did as a way of getting their doses of nicotine. Vaping is said to be much safer than smoking. But do you really want to vape long term – or even for the rest of your life? Who knows what will happen if you do this many times a day, every day for ten or twenty years?

Why do people start vaping? In most cases it’s a continuation of the reason they started smoking cigarettes – which they did typically as teenagers because their friends or parents smoked. They then found they couldn’t stop, or thought they couldn’t. Now e-cigs have come along. Wonderful! They can continue to ‘enjoy’ the ‘benefits’ of nicotine without (most of) the risks of inhaling smoke from smouldering chopped up tobacco leaves.

What smokers didn’t realise when they started smoking was that they were buying into an image designed to appeal to young people who were fooled into believing it would make them appear grown up, sophisticated and confident. Big Tobacco has spent billions in advertising its false promises and has made vastly more billions from the unfortunate people who have been lured into believing them and as a result have continued – in spite of knowing the dangers – to buy pack after pack after pack because they became hooked on the nicotine in the cigarettes.

And now, if you’ve taken to vaping as an alternative to cigarettes or just for the supposed fun of it, you can continue your addiction without (most of) the dangers of smoking. But you’re still addicted! And what’s so wonderful about vaping anyway? Do you see a vision of heaven or experience an orgasmic sensation every time you take a suck?

What vaping does for you is – nothing. Nothing at all – except give temporary relief of the need to take another dose of nicotine. And now, just as with cigarettes, many vapers find they can’t stop so they say they don’t want to stop. The very suggestion has them up in arms. Hence organisations, just like Forest (Freedom Organisation for the Right to Enjoy Smoking Tobacco), such as the New Nicotine Alliance in the UK (where, incredibly, it’s a registered charity) and similar ones in Australia and Sweden, have sprung up to defend the right of their members to enjoy being addicted to e-cigarettes.

But what if the alleged enjoyment provided by nicotine were an illusion?

Text © Gabriel Symonds

The Best Way to Quit Smoking

Now here’s something for smokers to ponder. The popular online medical information website, healthline.com, has a feature on ‘The best quit smoking apps’ for 2016.

Before we come to the list of the twelve winners we are reminded, in the usual encouraging way, that ‘Quitting smoking can be incredibly difficult, but it is ultimately worth the struggle.’ Never mind. Let’s check out a selection of their ‘picks for the best quit smoking apps of the year.’ They don’t seem to be arranged in any particular order.

Butt Out – Quit Smoking Forever in which you can ‘Track your cravings and how many times you end up smoking, then watch your progress over time.’

Craving to Quit which contains ‘Videos help to guide you through each step of the process.’

Get Rich or Die Smoking. This one ‘shows you what you can now buy with that money instead [of spending it on cigarettes]’.

There’s the cutesy spelling of Kwit which is for smokers who like games, it seems.

Smoke Free which enables you to ‘Log your habits and cravings, track how many cigarettes you’ve successfully not smoked’.

This is getting boring so I’ll pick just one more: Quit Smoking with Andrew Johnson. The reviewer seems to have forgotten that clichés should be avoided like the plague:

Like most bad habits, smoking can become a deeply rooted part of your routine…Sometimes it takes thinking outside the box to break through…uses deep relaxation to help send messages to your subconscious to help you kick the habit.

Apart from apps they list ‘The Top 8 Products to Help You Quit Smoking’. More  encouragement, put somewhat repetitively:

…quitting ain’t easy. More Americans are addicted to nicotine — the drug in cigarettes — than any other drug. And because nicotine is so addictive, it isn’t a drug you can just put down. Quitting can take several attempts…Quitting smoking is hard work.

The products, predictably, are nicotine gum, lozenges and prescription drugs. And one more I hadn’t come across before, The Quitter’s Circle. It’s another app:  ‘The revamped version includes many new features designed to guide Quitters through their Quit Plan.’

Techniques, methods, ways, tools, programmes, plans etc., to stop doing something, and now we have apps. This review of the winners for 2016 rubs it in that quitting (or kwitting) smoking is not just difficult but incredibly difficult and will be a struggle, not forgetting that quitting ain’t easy and is hard work. Gee, thanks.

There’s something wrong here. When I was doing my medical training it was pointed out to us that if many different treatments were recommended for a particular disease, it probably meant that none of them was much good. Another thing we learnt was that in order to treat a disease effectively you need to understand the cause, if possible.

This is the problem with the current orthodox approach to smoking. All the apps mentioned above are merely gimmicks of one sort or another.

Not one helps you understand why you smoke in the first place or why quitting seems so hard.

Text © Gabriel Symonds

Smoking in hospitals: right question – half-right answer

In a recent edition of The British Medical Journal (11 February 2017, p 232), that doughty source of the latest medico-political developments, there is a blog by a Dr Mary Black about the problem of smoking in hospitals, titled ‘Is it time we stopped colluding with smokers?’

I felt moved to send a response; it was published in the web-based version of the journal. This is what I said:

‘Dr Mary Black is properly concerned that smoking still goes on in many NHS hospitals due, it seems, to collusion by the staff who are too soft-hearted on patients. She cites her father, a doctor who was born in 1924 and started smoking in his teens. He ‘tried but failed to stop his tobacco use’ and died of a smoking-related cancer at the age of seventy-nine.

While it is regrettable that anyone should die of a smoking-related cancer, or of any kind of cancer for that matter, I would question the idea that he ‘tried but failed to stop his tobacco use’. With all due respect to Dr Black and the memory of her father, this is incorrect: he did not try to stop smoking; he only failed to stop, unfortunately for him.

The very idea of a smoker ‘trying’ to stop is wrong-headed and a distraction from the real issue (http://nicotinemonkey.com/?p=683). A smoker could be defined as someone who has failed to stop, and this is demonstrated every time he or she lights another cigarette, or pipe as in the case of Dr Black’s father.

She continues, ‘Misguided sympathy keeps the last vestiges of tobacco acceptability alive in the NHS…I now think that staff should focus their efforts on making sure that every smoker…gets nicotine replacement therapy and stop smoking advice’. Then she states the obvious, that the NHS should be smoke-free.

What would be wrong, then, with offering so-called nicotine replacement therapy to smokers who are admitted to smoke-free NHS hospitals?

This is what is wrong: for a start, nicotine replacement therapy is incorrectly named – it is cigarette replacement or nicotine maintenance therapy. But why should smokers need a replacement for cigarettes? This is the real collusion, based on misguided sympathy which in turn is based on misunderstanding of the nature of smoking. It also sends the wrong message: stopping smoking is too difficult to do on your own, so you need a drug in the form of medicinal nicotine to assist you. This disempowers and even infantilises smokers.

Of course the ‘stop smoking advice’ part is essential, but with the right sort of advice and understanding any smoker can stop easily – without nicotine. Many smokers actually dislike smoking (Proctor R, Golden Holocaust, University of California Press, 2011, p6) and may welcome the opportunity of enforced abstinence while in hospital. They would then be able to demonstrate to themselves that not only can they survive but also that they feel much better without poisoning themselves with nicotine in any form.’

Text (© Gabriel Symonds

Smoke-free but nicotine-trapped

I hope the copywriters of Public Health England’s ‘Smokefree’ campaign will forgive me for my satirical review of their efforts which I put in a chapter of my book, Smoking is a Psychological Problem. At least they were trying, however misguidedly, to help smokers to quit. Now the other day I wished to refresh my memory about a detail of this campaign and put ‘Smokefree’ into Google. I thought I must have mis-typed something because I landed up on a site that had me fooled for a moment. It was called, not ‘Smokefree’, but ‘GoSmokeFree’.

It seems to be a clever ploy to lure you into a site selling e-cigarettes and associated paraphernalia. For this purpose they include several pictures that suggest you’re in a chocolate shop.

Then they tell you:

Quitting smoking is not an easy task, there are numerous methods available to help you quit…One method more people are turning to lately, is the growing use of E Cigarettes (sic). If your goal is to remove nicotine from your body all together, then this option may not be right for you.

Is it just illiteracy, or are they trying to hide something with the careless wording? How do you remove nicotine from your body? If you cease to put any more in, it will over a few days remove itself. Then we have the ‘all together’ business. This means ‘all at once’ or ‘all in one place’. And if they’re saying ‘remove nicotine from your body’ in the same way that you might remove your overcoat when you get indoors and you do it all at once or all in one place, it makes no sense. Perhaps they’re trying to ask whether your goal is to get rid of nicotine altogether, that is, completely or totally. In this case, obviously, you don’t need e-cigarettes or any other ‘option’ to put more nicotine into your body.

I’ll give them the benefit of the doubt about illiteracy:

Becoming passionate about a new hobby is one way to take your mind off of (sic) smoking. There are dual benefits to a physical hobby as it will help you become healthier, and start to reverse the affects (sic) of smoking on your body, as well as take your mind off of (sic) cigarettes…Laws have been passed which bans (sic) smoking inside places such as bars, schools, cafe’s (sic), lunch rooms and shopping centres.

To show what good corporate citizens they are, they include advice on ‘The Benefits of Quitting Smoking’. To achieve this happy state, we are informed:

There Are 4 Key Steps To Going Smokefree. Join the millions of people of britain (sic) who have already gone smokefree! Every person is required (sic) to go through all 4 steps to achieve success.

This followed by the mysterious ‘Step 1: Interactive Body’. Although they tell you to ‘Download smokefree tools, along with videos and booklets’ where perhaps this is explained, there is no way I could find to do it.

They also make the controversial statement that ‘vaping has been advocated for by (sic) a number of agencies as a cessation device.’ I contacted them to ask who these agencies are. Answer came there none.

They do at least tell you, as they are required to do by law, that ‘Our products contain nicotine and nicotine is addictive’, and this is preceded by the word WARNING in red.

At no point, however, is it explained why anyone in their right mind would want put nicotine into his or her body at all.

Text © Gabriel Symonds

E-cigarettes are 95% safer than smoking! Or are they?

Is this what we want to see?

Among those involved in public health who see it as their task to ‘control’ tobacco by supporting measures to ‘drive down smoking rates’, as they put it, a new refrain has arisen that has almost become a mantra: E-cigarettes are 95% less harmful than smoking tobacco!

Some tobacco controllers get a bit carried away by this figure. We have the self-styled world expert on smoking and addiction, Professor Robert West, a psychiatrist, who is on record as saying: ‘If we fail to take this opportunity that electronic cigarettes are potentially providing then we’re really condemning [smokers] to death.’

Condemning smokers to death? Do we line them up against a wall or string them up from lamp-posts? What I guess he means is that if we (whoever ‘we’ are) fail to take this opportunity, etc., then you, the smoker, are going to die because e-cigarettes are not available because of unprogressive legislation or because it was believed they were dangerous when they weren’t.

What an strange idea. Because we don’t all rush to embrace e-cigarettes, many unfortunates who are suffering from the incurable disease of smoking will die. But all they have to do, to avoid an untimely death from this cause, is to stop smoking (unless they’ve left it too late of course).

Then there is Dr Colin Mendelsohn (http://nicotinemonkey.com/?tag=dr-colin-mendelsohn) who, likewise, believes in treating smokers with nicotine. He recently said in an Australian podcast: ‘[E-cigarettes are] a life-saving technology which allow people who can’t quit smoking to switch to a much safer alternative. We know that they’re at least 95% safer than smoking.’

Where does this nice round figure of 95% come from?

It first appeared in 2015 in a report issued by Public Health England called E-cigarettes: an evidence update, in which these drug delivery devices are promoted as a ‘tool’ for smoking cessation. The lead author is one Ann McNeill who, in these days of super-specialization, is a Professor of Tobacco Addiction in the National Addiction Centre. We’ll come back to her in a moment.

Another author is the clinical psychologist Professor Peter ‘nicotine-itself-is-harmless’ Hajek who, though he denies links with any e-cigarette manufacturer, has received research funding from and provided consultancy to manufacturers of so-called stop-smoking medications.

The Public Health England report was strongly criticized in an editorial in the prestigious medical journal The Lancet, which pointed out that the report’s conclusions were based on a study of ‘the opinions of a small group of individuals with no pre-specified expertise in tobacco control’. Oh dear.

Now it turns out that this study was led by none other than the well-named and eccentric psychiatrist Professor David Nutt, who in 2009 was dismissed as chair of the UK government’s Advisory Council on the Misuse of Drugs after saying that ecstasy, cannabis and LSD are less dangerous than alcohol and tobacco. He also believes that the psychedelic drug, psilocybin, can be useful in treating depression (http://nicotinemonkey.com/?p=739). Furthermore, two of the portly Professor Nutt’s colleagues are mentioned in The Lancet editorial as having potential conflicts of interest due to their associations with an e-cigarette distributor and manufacturers of smoking cessation products, respectively. Oh dear again.

The original ‘95%’ article (Nutt, D.J., et al., Estimating the harms of nicotine-containing products using the MCDA approach. European addiction research, 2014. 20(5): p. 218-225) is an account of an interesting theoretical exercise at a two day workshop in London in 2013. The participants used a complicated statistical formula and arbitrary criteria whereby, somehow, if ordinary cigarettes are regarded as 100% harmful, e-cigarettes are only about 5% as harmful. They did at least admit that ‘Our understanding of the potential hazards associated with using electronic nicotine delivery systems is at a very early stage.’ Quite.

The British Medical Journal also waded in with an aptly titled article, Evidence about electronic cigarettes: a foundation built on rock or sand? The authors point out a number of potential serious problems with e-cigarettes, among which are (paraphrased):

  • Children and adolescents may take up e-cigarettes and progress to smoking
  • The long-term effects of e-cigarettes are unknown
  • E-cigarette liquids contain formaldehyde as well as flavourings and other substances which may be harmful to health
  • If e-cigarettes are used to reduce smoking, as opposed to quitting, there may be no overall benefit for health
  • There is no evidence that e-cigarettes are effective as aids for quitting smoking
  • There may be a risk to bystanders from second-hand vaping in enclosed public places

Of course Professor Ann McNeill was not going to take this lying down. She became very cross at all this criticism of her ‘e-cigarettes are at least 95% less harmful than tobacco’ claim, especially at The British Medical Journal article which she called offensive.

The same confused attitude of the medical establishment to so-called recreational drugs is reflected in a cringe-worthy sentence in an article in The British Medical Journal (28 January 2017, p156) on ‘Novel psychoactive substances (NPS)’, or ‘legal highs’ as they are inaccurately known. In Britain it is illegal to distribute or sell them but possession is not a criminal offence. This being the case, the authors apparently think use of these substances is part of normal life, for there is a box headed ‘Information for patients who ask about NPS’.

This scenario is extraordinary. Can you imagine a patient making an appointment to see his or her GP and then saying something like: ‘Doctor, I’m think of using a “legal high” at a party this weekend. Could you please advise me how to do it.’

In spite of the fact that a large part of the article is taken up with a discussion of the risks and dangerous side-effects of these substances, this is the advice: ‘If using a novel substance, as with any drug, start with a very small dose and increase to obtain the desired effects.’

There is only word a doctor should say to anyone planning to use such drugs: Don’t.

But it seems with the addictive drug nicotine, because distribution, selling and use are at present legal, according to the Public Health England report, ‘it would be preferable for a young person to use an e-cigarette instead of smoking.’

How about not using nicotine at all, in any form?

Text © Gabriel Symonds

Photo by Philafrenzy, https://commons.wikimedia.org/w/index.php?curid=45613779

Australia Leads the Way: Vaping is Verboten!

What’s this? A smoking doctor? No, a vaping doctor! He has the unusual name of Attila Danko, which seems to be of Eastern European provenance, possibly Hungarian, and I hope he will forgive me for saying that this perhaps explains his passing resemblance to the actor Christopher Lee in his role as Dracula from next door Romania. He doesn’t look very happy. Is this what vaping does to you?

Dr Danko will now have an additional reason to feel unhappy. Australia’s drug regulator, the Therapeutic Goods Administration, has ruled that the already existing ban on e-cigarettes will continue.

In 2015 Dr Danko founded the New Nicotine Alliance Australia to push for e-cigarettes to be legalised. He admits he was a smoker for over thirty years and has ‘given up on giving up’ after switching to e-cigarettes. New Nicotine Alliance Australia’s mission, he says, is also to educate current smokers so they have the choice to switch. He thinks this would be a good move for ‘hardened smokers who can’t give up any other way’.

I don’t believe there’s such a thing as a hardened smoker or that any smoker needs to give up on giving up. The current orthodox approach to smoking cessation, however, may well encourage this nihilistic attitude, and it seems to me that what Dr Danko is saying, in effect, is that he’s mightily relieved to be able to continue in the thrall of his intractable nicotine addiction with allegedly safer e-cigarettes instead of ordinary cancer sticks.

Another part of the problem is shown in a view he expresses in a YouTube video: vapers should be able legally ‘to enjoy recreational nicotine’.

This is where the whole argument falls down. Nicotine is not enjoyable, nor it is a recreational drug.

If people who use nicotine are asked to say honestly whether they enjoy doing it, the answer is almost invariably ‘No’.

A recreational drug, of which the prime example is alcohol, is quite different. Unless you are an alcoholic, which most people are not, you can enjoy a drink as and when you choose, circumstances permitting. But virtually all people who use nicotine in any form feel compelled to do it many times a day, every day, for years on end.

If nicotine were a recreational drug, what is supposed to happen when you put it into your bloodstream and thereby cause chemical changes in your brain? Do you see visions of heaven? Do you experience some wonderful sensation? No. All that happens, though most smokers or vapers don’t realise it, is that the discomfort you were in before you smoked or vaped is temporarily relieved and this is perceived as enjoyable.

The Australian Medical Association’s sensible position on nicotine is very clear: it is highly addictive and there is no good reason to put it into your body in any form.

Note: The above comments are not intended as criticisms of Dr Danko. If he would care to contact me I should be delighted to prove to him (without charge) that he can easily abandon his dependence on nicotine.

Text © Gabriel Symonds

The Reluctant Quitter

Gentle reader, forgive my cynicism, but here we have another example of what might be called ‘The Hard Way to Quit Smoking’, this time from the website of New York City government.

As usual I’ll put selected quotes in italics and add comments, this time those an imaginary smoker might make as he or she reads through the site.

The title is How to Quit Smoking. Odd that you should need instruction in how to stop doing something. Why can’t you just stop?

Deciding to quit smoking is a step in the right direction. So you have to make the decision first and then you’ll have made a step in the direction of actually doing it. Only a step? How many steps are there?

It can be hard… Really? Oh, in that case I won’t bother. Why do they have to tell me it may be hard? Was I wrong to think it would be easy?

By preparing yourself, you will be more likely to quit for good. I see, so it really will be hard, but I can make myself more likely to quit. How much more likely? And more likely than what?

The following eight steps can help make quitting easier. So now they tell me – there are as many as eight steps! And even if I follow them all it seems it can only help to make it easier, not easy.

Step 1: Decide why you want to quit. Well, it’s obvious, innit? Would I want to quit if I didn’t have a reason?

Review your reasons to stay motivated. Quitting is hard… They’ve already said it’s hard – why do they have to keep rubbing it in?

Step 2: Get support and encouragement. Tell your family, friends and coworkers that you are quitting. Ask for their support. It really must be hard if I need support from my family, friends and coworkers. And if I ask for their support, what are they supposed to do, exactly?

Here are some resources to help you quit: Think about using quit-smoking medications, like the nicotine patch or gum. They can reduce your cravings and double your chance of quitting successfully. Oh dear, I need ‘resources’ to help me quit – like the nicotine patch or gum. That doesn’t make sense – I’m trying to get off nicotine! Do I really have to go through all that? And it seems I’m going to have cravings!

Step 4: Pick a quit date. Choose a quit date carefully. Select a day when your routine will be as close to normal as possible (i.e., no vacations, major work deadlines or major life events such as weddings, moving, etc.) All this business about pick, choose and select means it’s no good trying to quit when I’ve a major life event such as a wedding? But this is the main reason I want to quit – I’m getting married! And then I have another major event – we’re moving house! And I was thinking this was the best time to quit! I guess I’ll have to put off quitting smoking, but in that case my intended may not want to marry me!

Step 5: Identify and learn how to deal with smoking triggers. I’ve heard of smoking guns, but smoking triggers? Oh, I see, triggers (or cues) to smoke. What are these? Well, let me go the helpfully appended PDF on coping with triggers. Let’s see, the first one is Being around other people who smoke. And what do they recommend for that? Go to places where smoking isn’t allowed. Tell friends that you’re trying to quit. Brilliant, I’d never have thought of that. By the way, since I’m only trying to quit, I suppose it’s okay if I fail – tee-hee! Let’s look at another one: Taking a break at work: Try stretching or talk to a co-worker instead. I’m stretched enough as it is with all this trying to quit, and all my coworkers are smokers!

Step 6: Be ready to cope with cravings. This is getting worse and worse. Why do they have to repeat that I’m going to have cravings? And I need somehow to be able to cope with them!

I’ve have enough of all these steps. What else do they suggest? Ah, another PDF. This one’s called Don’t give up. But that’s just what I’m trying to do! Oh I see, they mean don’t give up trying to give up. Sense at last. And here are Other useful information and tips. What might these be?

Drink a glass of water
Pray or meditate
Distract yourself
Listen to music

Now I’ve got it! The way to increase my chance of quitting is to distract myself by drinking a glass of water while meditating standing on my head with music playing in the background. Impossible to smoke while I’m doing that!

Text © Gabriel Symonds

Cigarette harm reduction? What about harm abolition?

I have just come across an interesting presentation by one Maciej L Goniewicz, PhD, who works at the Tobacco Dependence Research Unit of Queen Mary University of London and the UK Centre for Tobacco Control Studies. So he should know what he’s talking about. Oh, and he receives research funding from Pfizer, a pharmaceutical company that makes drugs to help smokers quit, varenicline (Chantix) and a form of inhaled nicotine called Nicotrol.

The presentation is a review of e-cigarettes’ ‘efficacy and potential for harm reduction’. Let us get straight to the conclusions:

  • E-cigarettes deliver nicotine
  • After switching from tobacco to electronic cigarettes, exposure to all tobacco smoke toxicants examined so far is substantially reduced
  • E-cigarettes may be useful in reducing the harm of cigarette smoking in those who are unable to quit

I think most people by now are aware that e-cigarettes ‘deliver’ nicotine, that is, they deliver nicotine into the lungs of people who use them. Then the good news: the fumes produced by these devices contain much smaller amounts of the poisons found in ordinary cigarettes. And the conclusion of the conclusions? E-cigarettes may be useful (or maybe not, presumably) in reducing the harm of cigarette smoking – obviously, only if cigarettes smokers switch completely to delivering nicotine into their lungs with e-cigarettes – in those smokers who are unable to quit [cigarettes].

I have emphasized the last few words because they show the great paradox in this kind of approach to the whole smoking problem: all smokers are unable to quit – that’s why they’re smokers. Apart from this oversight, Maciej L Goniewicz, PhD, can’t seem to see the wood for the trees.

Let me explain. He’s been busy estimating the quantities of ‘toxicants’ that smokers and users of e-cigarettes, respectively, take into their lungs and has found that the latter ingest much smaller quantities than the former. But let us suppose, for the sake of argument, that the fumes produced by e-cigarettes – apart from the nicotine which is their whole raison d’être – are entirely free of toxicants of any kind. If smokers could be persuaded by common sense and logic to abandon their pernicious habit of inhaling poisonous fumes from burning tobacco leaf in favour of inhaling pure nicotine by using our hypothetical ideal (but so far imaginary) e-cigarettes, would that be a good thing?

To put the question in a slightly different way, would it be a good thing for millions of people to be wandering around sucking on these new-fangled devices to deliver pure nicotine into their lungs all day, every day (for that is what they do)?

Also for the sake of argument, we’ll put aside the question – and it is a very big question – that long-term use of e-cigarettes to deliver nicotine into your lungs may not be quite so harmless in the long run – let us consider whether it is, or should be, public policy that millions of people will be in the thrall of legalised drug (nicotine) addiction?

It is all very well to talk of harm reduction, as if cigarettes are a permanent feature of everyday life, just as one may talk of harm reduction in car crashes by enforcing the use of seat belts because cars are a permanent feature of everyday life and crashes will inevitably happen. But there is no reason why cigarette smoking should be regarded as being in the same category. If cigarettes were abolished tomorrow, would anyone – apart from the tobacco companies and their shareholders – be any worse off?

If the government are serious about harm reduction, and if they go along with the results of  research such as the above, let them abolish cigarettes at the same time as e-cigarettes and other non-tobacco products are encouraged.

Text © Gabriel Symonds