Tag Archives: Professor Robert West

Four Professors and a Counterfactual

All the fun of the fumes

The long-windedly titled The National Centre for Smoking Cessation and Training (NCSCT) recently produced a video called E-cigarettes safety: The facts explained.

The trouble is that there are precious few facts available at the moment; but there are plenty of opinions.

The film features four Professors who are well known e-cigarette enthusiasts and a layman, Clive Bates, Director of Counterfactual Consulting, whatever that is.

The OED, interestingly, defines counterfactual as ‘Pertaining to or expressing what has not happened or is not the case’ which perhaps explains Mr Bates’s view as stated in the film.

First let’s hear from Professor Linda Bauld, a behavioural scientist, no less:

We know from studies that nicotine is relatively safe.

What studies? What does she mean ‘relatively safe’?

Next we have Professor Robert West, a psychiatrist:

They (e-cigarettes) don’t use tobacco at all.

This is almost true, except that the nicotine in e-cigarettes is derived from tobacco.

Then Ann McNeill, Professor of Tobacco Addiction, explains:

Most things we do in life carry a risk. So, for example driving cars. Cars cause lots of road accidents, lots of people killed on the roads. But we don’t stop people driving. We try to make them (cars) less harmful.

This is a false analogy. Driving is a normal and essential human activity whereas smoking and vaping are not normal activities; they are undertaken only by drug (nicotine) addicts.

Finally we have Professor John Britton, an epidemiologist:

If we try to put a figure on the relative risk of e-cigarettes compared to smoking, my view is that it’s going to be well under 5 per cent of the risk…so we can be confident that electronic cigarettes are much less hazardous than tobacco cigarettes.

His view? How can we be confident? Just because he says so?

Then he makes a curious statement:

Where their safety lies relative to not using anything is much harder to place.

This is nonsense. Obviously there is no risk at all in not using anything, compared to using  cigarettes or e-cigarettes.

He does at least say something sensible – up to a point anyway:

Inhaling a vapour many times a day for decades is unlikely to come without some sort of adverse effect…It would be better avoided, but from the smoker’s perspective it is a far better bet than carrying on smoking tobacco.

A bet? So it’s all a matter of chance? He doesn’t seem to know what his point of view is.

Back to Professor West:

E-cigarettes are substantially less harmful than cigarettes and the reason that we can reasonably infer this is because of the concentration of chemicals that are in e-cigarette vapour compared with the chemicals that are in cigarette smoke.

So he goes from asserting that e-cigarettes are substantially less harmful than ordinary cigarettes to saying that it’s something we can only reasonably infer.

Professor McNeill again:

Flavourings are necessary for electronic cigarettes because people wouldn’t use them if they didn’t have some sort of flavours added. We need to entice smokers to use electronic cigarettes.

Does she realise what she is saying? How about enticing smokers to stop smoking and stop using nicotine in any form?

Professor West:

Some concerns have been raised about…the risks [of] flavourings in e-cigarette vapour…these are flavourings that have been tested and the concentrations are sufficiently low that we wouldn’t expect them to pose a significant health risk.

More opinion, supposition and guesswork. What if his expectations are wrong?

Professor Britton:

The propylene glycol…in electronic cigarette fluid…is used to make theatre fog, it is mildly irritant to the airways but is doesn’t seem to have any lasting long-term effects.

More guesswork. For how long and how often are people exposed to theatre fog? When did you last attend a theatre when there was fog?

He adds:

Glycerol [also present in e-cigarette vapour], likewise, is widely used in food. And again there’s no evidence or reason to expect it will have a significant long term effect on the airway.

Yes, it’s eaten in foods, but this is a different matter entirely from it being inhaled into the lungs!

And continues:

There is evidence that if you [are in a] room with somebody using one of these products (e-cigarettes) that there is nicotine and perhaps other chemicals in the atmosphere around you but at tiny levels. Levels not to be concerned by at all.

How does he know? What is the evidence? I would be concerned about unnecessary eposure to any levels of poisons.

Then he says:

I think if you’re in an enclosed space and somebody’s breathing out clouds of vapour that’s just unpleasant and it’s intrusive and it’s discourteous.

Quite.

Professor McNeill has an extensive list of publications to her name but has she actually treated any smokers? One wonders, when she makes statements like this:

The most effective way of quitting is to use a medication such as nicotine replacement therapy or it could be electronic cigarettes combined with behavioural support.

What does she mean ‘the most effective way of quitting’. Smokers who quit without medication or e-cigarettes combined with behavioural support haven’t done it effectively?

Professor West again:

E-cigarettes [are] there for people who…just want to go out to a shop and buy a product which they can use to stop smoking without seeing a health professional.

Why do you need a ‘product’ to stop smoking? Why not just stop?

And what does our counterfactual consultant have to say?

E-cigarettes [are] an alternative to smoking.

You don’t need an alternative to smoking!

Professor Britton:

E-cigarettes…normalise electronic cigarette use.

That’s the trouble!

And if we could normalise electronic cigarette use for the nearly nine million people in the United Kingdom who are still addicted to tobacco that could only be good thing.

A good thing for whom?

This is a product that can transform health…health-wise [smokers] achieve pretty much what they’d achieve if they quit smoking completely.

A huge assumption.

Do we really want to have millions of people sucking on e-cigarette drug delivery devices many times every day for years on end to gratify their nicotine addiction?

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

The Art of Medicine and Stopping Smoking

19c8ox9fnk82ljpgThe distinguished medical journal, The Lancet, in June 2016 reported the results of a huge multinational collaborative effort to investigate the risks of psychiatric side-effects of two drugs used in smoking cessation: varenicline (Champix®) and buproprion (Zyban®); no evidence of increased harm was found compared with nicotine patches and placebo (dummy) treatments.

This must have been good news for the funders of this study, Pfizer and GlaxoSmithKline, who also happen to be the respective manufacturers of these drugs.

The side-effects that did occur were nausea, insomnia, abnormal dreams and headache, but, it is said, these were no more frequent in the users of these drugs compared with nicotine patches or placebo treatment.

Well, that’s nice to know. Or is it?

Were these methods any good for helping smokers quit? They found ‘Varenicline was more effective than placebo, nicotine patch, and bupropion in helping smokers achieve abstinence, whereas bupropion and nicotine patch were more effective than placebo.’ All clear?

Incidentally, the investigators only looked at smoking cessation rates at nine to twelve weeks from the start of the study. How many smokers relapsed after that we’re not told.

They recruited 8,144 smokers; and ten people contributed to the writing of the paper – all from the US except one: Professor Robert West, the self-styled ‘world expert on smoking and addiction’, who is from the UK. Of the ten authors, five were representatives of the drug companies. Of course, there was absolutely no conflict of interest whatsoever in the conduct of this study or the reporting of the results.

So, the drugs varenicline and buproprion were more helpful than placebo in getting smokers to quit and they don’t seem to cause psychiatric side-effects.

Now let me pose a question: is stopping smoking really so difficult that you need to take a prescription drug to help you do it? But it’s worse than that: the fact that drugs are offered at all for this purposes merely reinforces smokers’ fears that quitting on their own is, indeed, difficult. Or very difficult.

A commentator in The British Medical Journal (25 June 2016, p521) made an interesting point about this paper:

[I]t seems to me that a government serious about protecting its citizens from the harms of combustible tobacco would simply make the stuff unavailable.

That’s the obvious solution to the smoking problem, but instead of the government taking steps – or at least talking about taking steps – to bring this about, it’s shifted the problem onto doctors. And doctors, with varying degrees of enthusiasm, have taken it up: smoking is a chronic disease; the recommended treatment includes medicinal nicotine or prescription drugs, or both. Now it’s almost as if smoking cessation has been hijacked by the medical profession, and in the process it’s being made more difficult.

In my previous post (Depression, Busy Doctors and Winnie-the-Pooh) I noted how there’s sometimes an unfortunate tendency to reduce the art of medicine to a mechanical process: diagnosis – drug. It’s operative here too: stop smoking – Zyban®.

Instead of reaching for the prescription pad, what about talking with patients? The inspirational words of a famous doctor, Sir William Osler, should be kept in mind: ‘Listen to your patient, he is telling you the diagnosis.’ And in this situation, not just the diagnosis but the key to successful treatment as well.

The doctor (or smoking cessation councellor) needs to be interested enough to take the trouble to try and understand why smokers really smoke and why it seems so difficult for them to stop. It will then readily become apparent that all smokers are in the same situation.

They smoke because of nicotine addiction – and nothing else. The reason it seems so hard to quit is because of nicotine withdrawal symptoms. However, the withdrawal symptoms are not that bad. They consist of mental symptoms – mild anxiety and nervousness. Not uncommonly the only withdrawal symptom is a feeling or an idea of wanting another cigarette or a vague feeling of discomfort. If the smoker understands this and can be encouraged and supported not to worry about it, something wonderful will happen: it will go away!

Nicotine products and drugs are not only unnecessary but they make it harder to quit; they should not be used.

Text © Gabriel Symonds

World Expert on Smoking and Addiction

With such a billing, who might this be?

It’s Professor Robert West, a psychologist and self-styled ‘world expert on smoking and addiction’ who thinks unless e-cigarettes are made available we’re condemning smokers to death (BBC interview, April 2014).

He published a book in 2013 with the intriguing title The SmokeFree Formula, A Revolutionary Way to Stop Smoking Now. Always keen to learn more about helping people to stop smoking, I bought a copy. But there’s nothing revolutionary about his approach – it’s entirely conventional.

It rambles on for 246 pages and is full of unnecessary words, tautologies and repetition.

Acknowledgements are made in a chapter headed ‘Thanks Go To…’ Why not ‘Thanks To…’ or simply ‘Acknowledgements’? Now he really gets into his hyperbolic stride: ‘I am deeply grateful to…’ (I am grateful to…); ‘Grateful thanks to…’ which occurs twice. (Thanks to…) Significantly, he expresses his grateful thanks to ‘several pharmaceutical companies that develop and manufacture smoking cessation treatments for their financial support…’ At least we know his potential conflicts of interest.

Let’s move on to the Introduction. There’s a subheading: ‘Read This First’. Introductions, if they’re read at all, are generally read first; that’s why they’re called introductions.

Unfortunately this introduction, which you’re urged to read first, is discouraging to would-be quitters because it emphasises the difficulties they’ll face:

Being bad-tempered is a classic symptom of nicotine withdrawal…There are so many things that could go wrong…incessant cravings…When the going gets tough…

Unnecessary words: ‘…by opening this book you have taken a huge stride to giving up smoking forever.’ (…you have taken a stride to giving up smoking.); ‘I’ll then show you how you blend these ingredients together into your own personal formula to be free of smoking forever.’ It sounds like a cookery lesson, but presumably he means to say something like: I’ll then show you how to create a personal formula to be free of smoking. Still with the cookery theme, lack of editorial vigilance is evident: ‘What ingredients you choose to use is (sic) entirely up to you.’ (The ingredients you choose are up to you.)

Professor West even bizarrely advises:

…you can think of stopping smoking as like (sic) looking for love

How can you compare a desire to stop poisoning yourself with tobacco with looking for love? He uses this inappropriate analogy to mean you keep trying till you succeed, but why rub it in that it’s likely to be so difficult?

At one point he even starts to sound like Jesus:

I want this book to be the best investment you ever make. I want you to be healthier, happier and have more money…I want to join you in your journey to a better life and be there to help you along the way…I will be with you for as long as it takes…

One might find something like this in Pseuds Corner in Private Eye (the British satirical magazine).

Reading the first chapter, called ‘Understanding Why you Smoke and Find it Hard to Stop’, Professor West’s approach emerges. He’s done research using questionnaires in which smokers are asked why they smoke and whether they often smoke in certain situations. Also, his team devised the ‘Mood and physical symptoms scale questionnaire’. In this, his subjects are asked, while smoking and when they’ve stopped, to rate their feelings over the previous twenty-four hours in terms of depression, anxiety, irritability, restlessness, hunger, poor concentration, poor sleep at night, sores in the mouth, constipation and cough/sore throat. With such leading questions the idea is reinforced that these are symptoms smokers trying to quit might indeed experience.

He does say one sensible thing: ‘Your brain has got used to nicotine and is now experiencing withdrawal symptoms because your nicotine level is falling.’ However, curiously, this idea is developed into the theory that ‘…nicotine has trained that part of your brain that gets you to do things to light up a cigarette whenever you find yourself in a situation where you would normally smoke.’ And the reason this happens, he says, is that nicotine indirectly causes dopamine to be released in your brain ‘which acts as a kind of reward’ and ‘It is this dopamine release that attaches the impulse to smoke to whatever situation you happen to be in when you normally do it.’ Geddit?

One wonders what sort of reader is being addressed by a style of writing like the following:

…these nerve cells need to talk to each other…Nicotine is like a cuckoo in the nest…your brain is being taught to sit up and beg for nicotine…smoking a cigarette is a bit like eating food when you are hungry, drinking when you are thirsty, telling a funny joke (Would you tell an unfunny joke?)…This chemical is called acetylcholine. (Don’t worry, I’m not going to test you on these names later!)…the bit of your brain that is giving you the urges to smoke is not the clever part. It’s the stupid part.

The discouragement continues:

…nicotine…has changed your brain chemistry to create powerful urges to smoke…you will have to show self-control…exert self-control and fight off the urge to smoke…you still need willpower…you start to feel a whole load of unpleasant symptoms when you can’t smoke…nicotine withdrawal symptoms come on very quickly and they are not pleasant.

And so on, and on.

Two chapters are dumbed-down lessons in the psychology of smoking and addiction, respectively. Among other gems, the author discretely mentions ‘…since you are so engrossed in my lesson in psychology…When I was first at university it took me a year to discover I didn’t really like staying up all night and partying…’ Well, fancy that! A hint of doubt on this confession does seem to creep in since he asks the reader, and presumably himself, ‘What am I saying here?’ Indeed. The introspective vein continues in the next chapter, ‘Why do you Want to Stop Smoking?’, opening with: ‘I’ve talked a lot about how nicotine keeps you smoking.’ Yes, he has.

Let’s move on to Part Two, subtitled with our now familiar cookery theme, ‘The Ingredients’.

The reader is told to ‘Think of this section as a storehouse full of useful ingredients sitting on shelves waiting for you to use them.’ (The last word is redundant.) Then he goes into the different types of evidence of effectiveness in helping people to stop smoking including the hallowed Randomised Controlled Trial.

Professor West describes his ‘Nicotine withdrawal: The train study’, which he conducted with Professor Peter Hajek, modestly introduced as the ‘founder of the model of group support given to smokers right across the globe’, whose other claim to fame is his assertion that vaping is no more harmful than drinking coffee (BBC op.cit.). No citation is mentioned, but apparently they took a group of thirty smokers and put them on a non-smoking train from London to Glasgow.

We then measured how they felt every 30 minutes during the four-hour journey. This was the first study anyone had ever done [these last four words are redundant] to see how quickly nicotine-withdrawal symptoms and urges to smoke emerged in a natural setting…

It’s hardly a natural setting. Thirty smokers, making an otherwise pointless train journey used a tick-box method to try to answer the above-mentioned question. Not surprisingly

We found that the mood of our volunteers started to deteriorate quite quickly, and…continued to get progressively worse…When the train reached Glasgow our volunteers couldn’t wait to get off the train and light up.

And the conclusion of this trial?

Nicotine-withdrawal symptoms come on very quickly and they are not pleasant.

This depressing result was entirely predictable. But I suppose the mention of this and similar experiments is only to be expected in a book written by a Professor of psychology who does research rather than who actually treats smokers. (I did ask Professor West if he had treated any smokers himself. He said he had, but declined to say how many or to enter into a discussion.)

This kind of research is very different from the approach where individual smokers are asked open-ended questions about what they feel when they haven’t smoked for a while or have tried to stop. In my experience it’s striking that most people find it difficult to say anything at all, other than that they feel they want a cigarette.

It seems curious to try to investigate smoking cessation by the same methods that are used in the scientific study of the treatment of disease. For example, it you suffer from a stomach ulcer, this can be treated with drug A or drug B and a randomised controlled trial can be done to see which, if either, is better. But smoking is an entirely voluntary activity. All the smoker has to do, if he or she wants to, is to stop smoking.

Chapter 7, ‘Your Approach’, we are told ‘…is all about you.’ This nice warm feeling, however, is quickly dispelled by yet another exposition of all the problems you are likely to encounter when you stop smoking:

The first four weeks are definitely the hardest from the point of view of cravings and withdrawal symptoms. There may well be times when you are hanging on by the skin of your teeth. You will need to do everything you can to keep from having that fateful puff on a cigarette…The next four weeks are easier…but if you are still finding it hard and your morale is sagging, things can be very difficult…After that…You may well miss your cigarettes…It’s just sooo (sic) easy to pick up a cigarette and smoke it. (Emphasis in original.)

Gee, thanks Professor.

Professor West is also at pains to stress 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.’

Well, that’s a funny way of looking at it. The definition of a smoker could be someone who has failed to stop: this is demonstrated every time he or she lights another cigarette.

A more accurate title for this book, it seems to me, would be: ‘The Conventional Way to Stop Smoking – 20% Success at Best’.

© Gabriel Symonds