If you wanted to sum up the current advice on tobacco control it would go something along the lines of tobacco plain packaging is good, so let’s move ahead with it as soon as possible, e-cigarettes are bad so let’s surround their use with increasingly restrictive controls. The Welsh Government is currently considering banning the use of e-cigarettes in enclosed public spaces, echoing the similar ban on smoking instituted in the UK in 2007.
While the ban on smoking in enclosed public spaces made sense given the evidence of the health harms associated with second hand smoke, the proposed ban on e-cigarettes is based on little more than the largely undocumented fear that e-cigarettes might ‘re-normalise smoking’, particularly among young people.
It is striking that many of those in public health who are now cautioning against e-cigarettes are the self same experts who had previously supported harm reduction in relation to illegal drug use. Over the last 20 years they supported the development of needle and syringe exchange services, substitute prescribing and a host of other harm reduction initiatives aimed at injecting drug users and others on the grounds that these initiatives might enable the UK to avoid an epidemic of HIV infection among injecting drug users, and largely ignoring the criticism that those interventions might serve to normalise an illegal activity.
The situation in relation to e-cigarettes could hardly be more different. E-cigarettes may well be the single most significant development in harm reduction for smokers but the trouble is they look like cigarettes and that, it seems, is enough to surround their use with restrictive control.
In stark contrast to the worries that public health advocates have expressed in relation to e-cigarettes, there is the unbridled enthusiasm for tobacco plain packaging. Packaging tobacco products in plain or standardised form was instituted in Australia in 2011, and in 2013 the UK government asked Sir Cyril Chantler to review the evidence on plain packaging with a view to considering whether similar legislation should be instituted within the UK. In 2013 an influential group of the UK’s leading tobacco control researchers expressed their frustration that the government had not already instituted laws governing plain packaging in a paper in the British Medical Journal with the title ‘UK government’s delay on plain tobacco packaging: how much evidence is enough?’
A further indication of the level of academic support for plain packaging can be gauged from recent research which involved asking 33 ‘internationally renowned’ tobacco control experts to estimate what they thought would be the magnitude of the impact of plain packaging on the prevalence of smoking among adults and children. All of the experts consulted were supportive of plain packaging, believing that this would result on average in a 1 per cent reduction in adults smoking and a 3 per cent reduction in children smoking.
In April the results of the government review were published, with Sir Cyril Chantler clearly persuaded of the benefits of plain packaging: ‘Having reviewed the evidence, it is in my view highly likely that standardised packaging would serve to reduce the rate of children taking up smoking.’ Speaking to parliament, Jane Ellison, parliamentary under secretary for public health, announced that she was ‘minded to proceed with introducing regulations to provide for standardised packaging’ and that she wanted to ‘move forward as swiftly as possible’.
The belief that plain packaging will reduce smoking prevalence is odd given that there has been hardly any research that has looked at the impact of such a policy on actual smoking behaviour. Researchers have looked at the relative attractiveness of plain and branded cigarettes packages, the salience of health warnings on plain and branded packs, and the degree to which smokers infer information about the harm and strength of tobacco on the basis of pack design and colour. What they have not done is to measure how much the prevalence of smoking and the number of cigarettes smoked actually reduces once cigarettes are packaged in plain form.
The lack of evidence that plain packaging reduces smoking prevalence was conceded recently when the Mexican government asked the Australian government for the evidence on which they had based their plain package policy. The health minister, Nicola Roxon, responded: ‘Well this is a world first. The sort of proof they’re looking for does not exist.’ Cyril Chantler also seemed to concede the lack of evidence on the impact of smoking prevalence in his review when he commented: ‘Although I have not seen evidence that allows me to quantify the size of the likely impact of standardised packaging, I am satisfied that the body of evidence shows that standardised packaging in conjunction with the current tobacco control regime is very likely to lead to a modest but important reduction over time on the uptake and prevalence of smoking.’
So why are the public health advocates who supported harm reduction measures in relation to illegal drug use so enthusiastic over plain packaging and yet so cautious over e-cigarettes? The difference here is that when harm reduction measures were being considered in relation to illegal drug users it was the greater fear over the possible spread of HIV that led to the enthusiasm for developing needle exchanges and other interventions. In relation to tobacco, there is no fear greater than that over smoking-related health harm, and no priority greater than the priority of subjecting tobacco to increasingly restrictive control.
As a result, the harm reduction inclined public health advocates find themselves urging the government to get on and implement tobacco plain packaging while worrying darkly that e-cigarettes might re-normalise smoking and advocating that their use should be subject to increasingly restrictive control.
Neil McKeganey is director of the Centre for Drug Misuse Research, Glasgow