Sally: I'm going to pose to you the kinds of objections that at least our public health
community, not everyone, I mean, there are some folks who are responsive to data, but
there is a lot of ideology driving the resistance, and I'm gonna name the four basic arguments
against it.
One is that it normalizes smoking.
A lot of this concern surrounds the children.
It normalizes smoking, it will be a gateway to smoking.
Dual use, in other words, continuing to smoke while you vape is not a good idea, and nicotine
is dangerous.
Clive: Okay.
Okay, so renormalizing smoking, it's never been that obvious to me why the emergence
of an alternative technology to smoking somehow normalizes smoking.
Surely, what it does is normalize the alternative behavior, which is giving up smoking by switching
to vaping.
No one has ever provided any compelling evidence that this is actually this bizarre thing.
When you think about it, it's a bizarre claim that you launch a new product and actually
what it does is increase sales and use of the old product.
It doesn't do that.
It does exactly the opposite, and there's no evidence to support it.
It's just a made-up argument that has no basis in reality, and to be honest, it doesn't really
have any basis in plausibility.
Adverts for e-cigarettes, marketing of e-cigarettes market e-cigarettes.
They market an alternative.
Sally: Gateway?
Clive: Gateway effect.
First of all, there are the people who talk about the gateway effect.
When you actually say, "Well, what exactly do you mean by a gateway effect?"
What you'll get is some slightly confused or very confused, often, things about, "Well,
they started on e-cigarettes and then they went to cigarettes, okay?
And that means the e-cigarettes were a gateway."
It doesn't mean that at all.
To understand whether there was a gateway, what you have to do is imagine a world without
e-cigarettes and look at all patterns of smoking there would be.
So some people never smoke, some people would smoke.
And then you introduce e-cigarettes into that world and those pathways all change.
So some people who smoke would switch to e-cigarettes and then maybe quit completely, and that's
a gateway exit.
That's a good gateway.
Those are the gateways we want.
So then you have to find...to find a really harmful gateway, you have to find someone
who would never have smoked, and bare in mind, it's hard to know that.
They have to then switch to e-cigarettes, which does them a bit of harm that they wouldn't
have done to themselves otherwise.
And then they have to move on and graduate to the big harm, which is smoking.
So finding people that have gone down that pathway is extremely difficult.
No one can really produce the people that have done that.
None of the studies really do show that, and none of them are set up to do that kind of
follow-up work or to measure people as they progress through these things.
So what happens is that people overclaim on gateway effects.
They find associations between vaping and smoking and then they conclude that the vaping
is causing the smoking.
What is much more likely, though, is that the same things that incline people to smoke
are the same things that incline them to vape.
In other words, there are same personality characteristics that cause the two things
to happen.
And if they take up vaping and they would have otherwise smoked, it's a benefit to them.
So I don't think there's anything in the gateway effect, and when the Royal College of Physicians
looked at this, and Public Health England, they said, "First of all, the concept's so woolily
defined, it shouldn't even be used."
And certainly, there's no evidence to suggest that's happening on a meaningful scale.
Sally: Yeah, and the epidemiology certainly bears that out in that there are fewer and
fewer teens who are smoking.
So if there were...
Clive: Yeah.
That's the big story.
If there was a gateway effect, where are all the people who are emerging the other side
of the gate?
Sally: Right, exactly.
Clive: You know, they're not there.
In fact, teenage smoking is falling to the lowest levels and at the fastest rate in history,
coinciding with the rise of vaping.
So it suggests that if there's a gateway, it's an exit, not an entry to smoking.
The other one was dual use.
Clive: Okay.
So dual use, it's odd that people think that dual use is a bad thing.
If somebody starts using a different product instead of smoking, there are a number of
good things that could come out of that.
First of all, if they carry on, then their risk is likely to be reduced.
Some of the health effects of smoking are proportional to exposure.
And therefore, if you reduce your exposure...
Sally: You have the respiratory effects.
Clive: Yeah, exactly.
And actually, cancer effects as well.
Sally: But the cardiovascular, we're not so sure.
Clive: Cardiovascular, there's some doubt about where there's non-linear effects and
so on, so there may not such a benefit there.
But hell, respiratory cancer, that's something.
Sally: That's huge.
Clive: Then it's the argument that actually many...you have to look at this dynamically.
So if you just take a snapshot, you may be missing the fact that people are on a lengthy
transition.
They're going from being 100% smokers and they're gradually shifting through dual use
to not smoking at all, or smoking on an occasional basis.
And then the final thing I think to say about dual use is it's not one thing.
You know, somebody who vapes all the time and then smokes a bit at the weekend when
they've had a few drinks, they're not at particular risk.
Occasional smoking isn't a big deal.
It's daily smoking that you need to worry about.
And of course, they are very different to somebody who smokes all the time and vapes
every now when, you know, they're not allowed to smoke.
So those are two people who would both be classified as dual users, but their pattern
of use is completely different, that it's meaningless to lump them together in a single
category.
So you need to dive into the data to understand what's going with dual use, but it's definitely
not a bad thing.
It's only goodness comes from dual use, no badness.
Sally: Nicotine?
Clive: Well, nicotine has been studied extensively for many, many years in a way in which it's
consumed separate to smoking.
So nicotine replacement therapy patches and gums and smokeless tobacco, Snus, for example.
It's pretty clear that nicotine is not the harmful agent.
It's not completely benign, but then caffeine isn't completely benign either.
Nicotine does have some effects on the body, so, you know, it changes pulse rate.
It has effects on the cardiovascular system.
And what people have been doing is they'd been measuring those effects and going, "Oh,
look, something bad is happening."
But actually, that's normal.
Those bad things happen when people take caffeine, when people go running, when people listen
to rock music.
You see physiological responses to these things, but they don't necessarily lead to people
keeling over dead with heart attacks and strokes in the future.
Sally: And they tend not...in many of these studies that look at the effects of vaping,
they don't compare them to cigarettes because the whole keyword here is "relative."
Clive: Well, the Surgeon General did a very exhaustive review of the health effects of
smoking, and the conclusion of that was that the things that cause cardiovascular disease
in nicotine is the products of combustion like carbon monoxide, oxides of nitrogen.
They're just not present in e-cigarettes because there's no combustion.
So I think they're trying to argue that nicotine is a harmful agent because it's integral to
the product.
You obviously can't take it out or it's no longer a substitute, but we've never heard
in the past about passive nicotine exposure.
We've never really had the emphasis on nicotine as the harmful agent until now.
And the truth is it's not completely benign.
There may be issues for pregnant women or for teenagers, but in all circumstances, it's
better to take nicotine from an e-cigarette than nicotine from a cigarette.
Absolutely no question.
Whether you're pregnant, whether you're four years old.
That is always an improvement.