Clive Bates on the E-Cigarette Revolution

any type of drug. Hello Psychoactive listeners. Today we're gonna get into an issue that's not about illegal drugs, at least not yet. It's an issue that I kept an eye on all those years I was running the Drug Policy Alliance and dealing with the consequences of the war on draws US. But this one has to do with tobacco and nicotine and the question of whether or not the whole idea of harm reduction applies as much to

tobacco products and smoking as it does with the illegal drugs. Now, around the time I was stepping down from DP about four years ago, the whole phenomena a jewel came around

kids Jeweling and using East cigarettes. I mean, these cigarettes have been around for a while, but there was this explosion of adolescent vaping with Jewel and some of the competing products, and this public hysteria in the United States that resulted in all sorts of localities and even states starting to ban these products, and with people kids and adults being told that these cigarettes were as are more

dangerous than cigarettes. And meanwhile, there's all sorts of evidence out there that adults who have had a really hard time quitting smoking could really benefit from making the switch to eat cigarettes. So this issue has been seriously in the news. In fact, but for the COVID pandemic, we'd probably still be talking about the vaping epidemic. Now, it's the f d a's job to regulate this industry, and

they delayed doing that for many years. But they're supposed to issue a ruling, uh fairly soon about what this entire e cigarette industry is going to look like. You know, which flavors can be sold, if any of these things can be sold at all, how much nicotine can be put in, whether just to allow tobacco flavors, what restrictions on access to kids, So whenever the FDA rules. This

could fundamentally reshape this entire industry. Until then, though, I want to provide some introduction to the issue, and I'll tell you that as I was learning more and more about this issue over the last few years, it was just one name that just kept popping up, left, right and center. And that's my guest today. His name is Clive bates Uh. He was a leading figure in the United Kingdom in late nineties and only two thousand's in

the fight against smoking and big tobacco. He ran the leading anti smoking organization, which in the UK is called Action on Smoking and Health or ASH, and he stayed active in this area ever since and really emerged as really perhaps the outstanding expert and in some respects propponent of tobacco harm reduction. His website, Clyde based dot com is probably the best resource in the world on this issue. There's probably nobody I've learned more from on this issue

than Clive. So Clive, thank you so much for joining me today. Him it's a real pleasure to be here. I've been a long stunting admira of you into your work on the war on drugs. So I promised our audience that with people whom I agree with a lot, I'm going to avoid this being any kind of love

fest or disagreement fest. So what I'd like you to do is start off by just laying out the overall argument for why things like jewel and others were maybe good things, and why maybe people shouldn't be as worried about the whole kids thing or about this as most of my country and many other countries seem to be. Well. First of all, we have to start off with a definition of the public health problem, and that is that smoking, even now is a massive killer worldwide. W h O

says eight million deaths per year um. Typically. I think in the United States they would typically say four under an eighty thousand premature deaths per year, and in developed countries tobacco would be killing or smoking would be killing more than obesity, alcohol, road accidents, drug misuse, and HIV combined. Now, the pattern of illness, it's a sort of late onset problem. So the median lifelong smoker would typically be losing around ten years of life in their seventies, so that's the

sort of shape of the problem. But really after the sort of mid thirties to forties, people who smoked all their lives are starting to die prematurely from cancer, from heart disease, from serious lung ailments like emphysema, and so on. So that's the basic problem. Now, that problem is caused by smoke, not by the underlying drug using pattern. Okay, Now, just to unpack that slightly, People are smoking and using tobacco for the nicotine that is the recreational drug habit involved.

You know, it's a relatively in drug terms, a relatively benign drug. Doesn't cause intoxication, and it doesn't cause people to lose control, it doesn't cause violence, it doesn't call family breakdown typically, and so on. But the harm is done by the mode of delivery, and the mode of delivery is to set fire to tobacco in the tip of a cigarette and inhale the products of combustion in the form of a kind of nicotine bearing aerossault. And those products of combustion, the tar and the hot gases

that you inhale, those are the things that cause the disease. Now, what we have now is a range of products that don't involve combustion but allow users to consume nicotine. So these would be vaping products, heated tobacco products, smokeless tobacco products like snooze, and these new oral nicotine products are kind of pouches that don't contain tobacco but do contain nicotine.

You're put in your mouth and absorb the nicotine through the mouth, And if you can take nicotine without the smoke, then you are likely to be avoiding all or nearly

all of the disease risk that affects smokers. So there is a massive harm reduction potential in these smoke free products, of which the product Jewel that you mentioned, Ethan is you know, one amongst many, but one of those that has had the most spectacular success in terms of switching smokers from a smoked product to a smoke free product.

And the more of that we can do, the more that we can convert the world's stock of around one billion smokers to smoke free forms of nicotine, the more that we're in in play to get a massive public health dividend out of migration from combustible to noncombustible forms of nicotine. So that's the basic public health problem and

the harm reduction premise explained in overview terms. So now when I look at public opinion polls in the United States, we now see that a majority of Americans think that vaping are using a jewel or e cigarette is as or more dangerous, and cigarettes we see a majority of people believing that nicotine is why cigarettes cause cancer. So basically, what you're saying is that these public perceptions are the

opposite of the truth. Those public perceptions are completely wrong, and they are very dangerous because people act on the basis of their perceptions, and if you hold those perceptions, you would be indifferent to whether you're consuming nicotine by smoking or by vaping, or by heated products or by smokeless tobacco, and you should not be indifferent about that. The health risks are radically different. And we know this

really beyond any reasonable doubts. So if you measure hazardous agents toxicants that you find in the blood urine saliva of people using these products, you'll find dramatically lower levels amongst people who are using smoke free products. Then you would find among people who are smoking cigarettes almost the same in many cases as non smokers, or down to the levels where people quit smoking. And therefore it's just

completely implausible that there would be the same disease risk. Now, some people say, well, you just don't know about the long term future, and of course, you know, we don't have time travel. We can't go forward forty years and find out what happened from prolonged use of products that were only invented, you know, ten, fifteen years ago. But if you have dramatically lower exposures, it's a pretty reasonable assumption that you're going to have significantly lower disease risk.

And maybe you're going to be below the thresholds that the body can deal with and have negligible disease risk, you know. And if you're losing from lifelong smoking ten years of life in your seventies, maybe you'd be at worst losing a few months. And then you start to get a risk behavior where the risks are kind of in the noise of other things that you do in life,

whereas smoking is not in the noise. It is an outlier in terms of personal risks are assumed through substance use or consumption, or lifestyle or behaviors of any sort. So I don't buy these ideas that anything like equivalent. One final thing to say about this ethan, though, is that this is not accidental. People have those perceptions because those perceptions have been implanted by an expert community of academics, of activists, of public health officials who don't want you

to think that these products are lower risk. They don't like the harm reduction concept. They think everybody should cease using nicotine completely, and therefore a much safer way of using nicotine in their world works against their ultimate goal, which is a nicotine or drug free society. And it's no accident this people work tirelessly to confuse the public about the risks of using these products. It's despicable, it's irresponsible,

and they're not accountable for it. But that's what's going on. Yeah, I will say. I mean, it's been stunning to me when I look in the political environment and see that some of the most vociferous anti harm reduction folks in the tobacco field are the people who are my allies

on drug policy reform. You know, the governors, the senators, the congressman, the local legislators who were my allies on legalizing marijuana for medical purposes and more broadly, on advocating for needle exchange and harm reduction with illicit drugs, are the ones introducing bills and banning these cigarettes. So before we get into why that's happening, let me just ask you, in greater specificity, some of the things that I hear from this other side. Right, one of them says, Okay,

maybe east cigarettes are good. If you're smoking and you can't quit entirely, then it's good to switch to an east cigarette or a heated tobacco product. Many of them will admit to that, but they'll say, what about the kids.

I mean, first of all, you now have kids vaping who never would have touched a cigarette, but they're getting into vaping, and then they're getting addicted to vaping, and it can't be healthy for you to just be inhaling this stuff through these electronic devices where we don't really have long term studies. I mean, how do you respond to that class? Well, I don't think anybody approves of any kids doing anything risky, you know, drinking, taking drugs,

drink driving, having premature sex. There is a whole range of risk behaviors that young people enter into that adult society generally would rather they didn't. But the problem is they do, and they do that partly because adolescens are in a kind of graduation process from being children to being adults. Adults use these substances, so they do. Therefore, I I think you just have to recognize that risk

behaviors are part of life. They happen to be concentrated in kids that have usually had a bit of a tougher life. They haven't done well at school, their families are not always as sort of robust as you would like. They may have some mental health issues, they may be in poverty or so on. So you see, the underlying

causes of these things are pretty fundamental. And therefore I would start from the position, and this is an unpopular view, I I you know, I don't deny that that some kind of drug use, you know, is a given in all societies everywhere, from ancient history onwards, and will probably continue to be. And therefore the sort of job of adult society is, to the extent it can not just to condemn it with a sort of just say no message, but to ensure that the options available are as safe

as possible, are not outrageously dangerous. At least there are good options available if you want them. Now, with vaping, there's a lot of very frivolous behavior going on, it's a new thing. You can do silly things like blowing big clouds with them. They're slightly funky tech gadgets and so on. So what we find with youth vaping is that there is a lot of infrequent use. So this is kids basically being kids, messing around at parties, blowing

big clouds and being silly. It's not an unusual thing for kids to do that, and it shouldn't be causing people to go mad with concern about what they're doing. When you look at more frequent users, so people who are using the products you know, most days or every day, what you find is that those are the kids who did or would be using tobacco anyway, and they're they're you know, around a one third of us teenage vapors

would otherwise be typically smokers. Now for them, the intriguing thing here is that vaping maybe a diversion from doing something worse i smoking. And there's some evidence in the time series data that suggests the arrival and rise of products like jewel or vaping products more generally has caused a diversion re effect in the trajectory of smoking. In other words, it's accelerated the downward trend in smoking and vaping is effectively displacing smoking in the teenage population, and

that's a good thing. So I think when people talk about youth vaping, you have to take a much more nuanced view of it. How much of it is frivolous, how much of it is more you habituated, and of that, how much of that is a diversion from smoking? And for goodness sake, let's take youth risk behaviors in context. Vaping is amongst the most innocuous things that kids do, amongst the whole spectrum of dangerous things that you know kids do, and it's not Honestly, I think government agents

or anyone else should really be focused. Look at the opioid epidemical, you know, binge drinking. I mean, I hear you talk about you know who, who's who's smoking, who's vaping? And I think we know from the evidence that smoking at this point, I mean, when I was growing up, I think he was likely to see upper middle class,

wealthy lawyers, doctors, teachers, professors smoking as poorer people. But now it really is among people lower income, white and black, right is among people mentally ill, among LGBT community, etcetera, etcetera. But what struck me about the phenomenon and jeweling, and here I should say, you know, like jewel is to eat cigarettes, right more or less, like Kleenex is two tissues, or xerox is to copy machines, or maybe even like

produce pharmace. Oxy content was toxy codon right where it's plays a big role in the market, but it seems

even more dominant because it's become a generic name. What I was struck, especially in places like San Francisco and other cities, and even where I live in New York, was that what was happening was that middle upper addle class kids, kids go into the private schools that you know, living in the fancy neighborhoods, that they were beginning to vape and getting into jewel and sometimes having a hard time stopping. And their parents, I mean their parents either

had never smoked or hadn't done it in decades. They basically don't hang out with people who smoke or vape. They think they don't know anybody who smokes are vape. I mean, the only people they know smokers are vape are probably the people who work for them, and those people don't do it in front of them. So these upper middle class who can call their local legislator are finding their kids vaping and they're totally freaking out that, my god, my kid was not going to smoke at all,

so he's doing this stuff. And then they read like, oh my god, the adolysts and brain is vulnerable, and what do you say about that? All right, So there's a couple of things that even I mean, first of all, you're absolutely right. You know, the concerned soccer moms have enormous political cloud and their definition of the problem, which is that their kids doing this is you know, a national crisis of aping epidemic. Is how that has played

in the media. I don't think the data is fully in on that yet, but I don't think that will actually play out. When we have all the data. What we'll see is that most of the better off kids will be amongst the more frivolous users. And also they will be the ones who give up, you know, fairly quickly, either after they leave school or after they leave college, that they get serious jobs, they settled down, have families and so on. That's at least what the history of

smoking has told us. If you go back to the time when you know, you had twelfth grade, you might have had thirty of young people smoking. What you'd have seen is a fairly even social economic distribution, which then consolidated into a sharp socioeconomic gradient as the better off kids gave up as they entered you know, if you like middle class society, and I suspect that we will

see that again as those kids age into their twenties. Again, if we're really concerned about this would be focused on the disadvantage kids, the kids who would be smoking now and are now vaping instead, or at least now have the option to vapor instead of smoking. That's where there's a public health win. And of course the soccer moms who are you know, running points on this campaign, pay no attention to them. They're not really interested in the

class basis of youth vaping. They're interested in the middle class basis of youth vaping, and they're missing something really important because of that. You know, I was gonna say, I mean, you know, it's obviously people are worried about their own kids, and obviously when upper middle class people are worried about their own kids, that's a politically great significance. But you know, one thing is Jewel came up with his product right there was particularly innovative, like a little

thumb drive a good effect. But what argument could be, Okay, let's ban the products that kids seem they are so attracted to, even if the adults like them as well, but allow the products that don't seem as appealing to kids, like these heated tobacco products, heat that burn, right. Philip Morris just guide its product called icos right, which is a kind of bulkier product and seems to be effective

as a harmonduction device. Why not just allow the heated products and say no, you can't do those, these cigarettes or things that where kids are going to be drawn to them. Well, I think the first thing to say about that is that vaping is enormously popular with adults, and the dual product has had amazing success in converting adults smokers to vapors. And the reason is that it the whole package of it works very well for smokers.

It's easy to use, delivers it can if you want it to deliver nicotine roughly the same levels that cigarettes can. It's small, it's compact, uh uses low volumes of liquid, and it looks Okay, so that package has been very, very attractive with smokers. It's not obvious that, you know. I think one of the things that smokers are trying to do is they're trying to get away from the

experience of smoking. So the heated tobacco products are very good and they work for some people some of the time, and one of the reasons that they work is the experience is closer to smoking. So for people who want something that is a closer substitute, they work very well. But the whole bunch of other people who want to migrate away from smoking and end up using a flavor that is, I don't know, peach Melbourne or something that

has no echoes or cues associated with smoking whatsoever. So I think you've got to be really careful before you say, well, on the basis of these kids using these products, we're going to stop the adult smokers who are actually the at risk population from having access to these products that

they really like and work for them. And at the same time, you've also got to keep coming back to this, You've got to be mindful that there's a lot of kids who would otherwise be smoking, otherwise doing other risk behaviors. And I think if I was one of these concerned parents, if you were to sit down and rank the list of things that you should be worried about as a parent, Okay,

drink driving would be up there at number one. I mean, kids getting smashed up in cars is the number one cause of death in the age range from fifteen to twenty four, and that's driven by reckless driving, often fueled by alcohol, So that I think would be my number one. I would be really concerned about vulnerabilities caused by alcohol, the risk of violence, the risk of sexual assault, and

so on. I would be concerned about some of the things that are going on now, like cyber bullying, some of the things that go on in terms of the way social media are used. I would be really concerned about kids mental health status, what's going on with self harm and kids being depressed and suicidal ideation and so on, And be extremely concerned about any uptake of opioids and

use of fentanyl. As I say, I think it's important to get these risks, the risk associated with vaping, which are very very low in context with the whole panoply of youth risk behaviors, and behave accordingly and recognize that for a whole section of the population, these vaping products are extremely beneficial and maybe life saving for them. So it's not just that vaping is a lesser public health problem and smoking. It is actually a huge public health

benefit for smokers who managed to switch. And that's the kind of grown up discussion we need to have about these products, including with parents and the flavors issue, because sometimes hear people saying, Okay, allow the tobacco flavored eat cigarettes, but band you know all the ones that the kids like, what's your response to that. Well, I mean, there's a lot to say about that. But obviously the purpose of flavors, I mean, it can't be denied, and it's trivially obvious.

Flavors are put in the products to make them more attractive. And if you have an unflavored vape doesn't really taste of anything. So what you're trying to do is create a rival proposition to smoking. Now, smoking is full of flavor. It's not added flavors, but it's full of flavor that comes from the smoke, the actual products of combustion. So to satisfy somebody who smokes, you need something in its place. You need the products to actually taste interesting and be good,

otherwise no one will use them. It simply won't play a role in displacing smoking and driving down smoking related disease. The interesting thing about the flavors debate in the United States is that the activist community, the anti aping activist community, started off saying, well, we shouldn't have things like gummy bear or cotton candy flavors because these are obviously childish type things. And then they discovered that kids were or

adolescents were taking up duel. But duwel comes in fairly bland, well, fairly bland sounding flavors, so cucumber, mango, crem so these flavors were not in any way targeted at kids, but because kids were using them, the activist organization said, ha ha, those must be kids appealing flavors too, so we need

to ban all of those. So what started off as a niche proposition that you would ban things that were obviously childlike like gummy bear or whatever, suddenly massively expanded in scope to include every flavor that wasn't a tobacco flavor. So the real fanatics in this field now, so you should ban every flavor that isn't a tobacco flavor, And for some reason they think it's a good thing that the only vaping products you should have on the market should,

as far as possible, resemble cigarettes. I simply don't understand the logic of that, so I don't agree with flavor bands where I think you could do something. There are basically three ways of controlling flavors. The first is as a chemical So do the chemical agents in this flavor cause cancer? Are the immutagenic? Are they reprotoxic? Are the respiratory sensitizers? So treat them as toxic agencies? And if they are, then don't allow them or restrict them in

some way. Secondly, you have a flavor sensation, so you subjectively decide that this product taste of apple, or it tastes of key lime pie, or it tastes of tequila sunrise or something that is a much harder thing to interact with that that's a subjective opinion of what the flame that is, and I don't think you should be trying to ban that. The third area that you can

regulate in terms of flavors is the flavor descriptor. So you know, we call this gummy bear or we call it cotton candy, or we call it unicorn vomit, or we call it something that is designed to capture the imagination of kids. Now, that is an area where I think you could justify intervention, not so much the flavor itself, but the communication about the flavor and the attempt to appeal to kids. Now, I happen to think that a lot of adults like childish sounding things, as well as

a lot of nostalgia and retro in there. But if you're going to regulate anywhere, I think it should be on the descriptors, not on the flavors themselves. We'll be talking more after we hear this add So some people say, I mean, the UK seems to be United Kingdom seems to be one of the models for embracing to some extent,

a harm reduction approach. You know, even e cigarettes tapes can be sold in hospital shops, and you know, the governments started behind getting people to transition, and it appears that the uptake among young people is much lower than in the US. But some people then say, well, that's because the UK limits the nicotine level of these cigarettes. You know that jewel or others are what is it fifty milligrams or whatever. In the UK, it's got to be half or a third of that. So what about

restricting the nicotine content. Well, again, there's a lot to say about that. I mean, people have noted that there's a limit of on the strength of nicotine in the cigarettes in Europe and still including in the UK. It's very difficult to show that that is the reason why there is a low level of the cigarett at uptake in UK kids. We do have the problem that I don't think products like the Jewel product have been anything like as effective at converting smokers in the UK as

we've seen in the United States. It's a bit hard to really understand why cigarette smoking or vaping goes up and down anywhere, but I suspect it's something to do with fashion, with the way group preferences are are formed, and I have to say I think it's probably something to do with the near hysterical levels of moral panic

about vaping in the United States. C d C did a survey I think it was two thousand and eighteen and looked for the reasons kids said that they were taking up vaping, and the number one reason was curiosity and flavors were number three, and you know, less than half of the kids cited that compared to curiosity. Now, if you've got every newspaper, every parents, every teacher, every agency, every TV station blasting out at you, hey, kids, all

other kids are doing this. People think it's fashionable. People think it's really cool. Look here's how you hide it in your rucksack. There's a whole bunch of kids that can even do it in class. You've got these sort of bizarrely weird anti vaping campaigns that sort of, you know, hark back to sort of reefer madness, kind of levels of bizarreness. I just suspect that that may actually be a contributory driver, because which respectable kids says, well, this

is something I must now try. If adult society is this upset about it. In the UK, the whole thing is much more mundane. The government advertises e cigarettes on television and pitches it at rather uninspiring kind of forty plus year old people. It looks like something that kind of more older people do as an alternative to smoking, and we don't have everybody losing their minds about it. It's seen as something that's good for health, and something

that you should do if you're a committed smoker. That's how the positioning has been. So I think those reasons are probably more likely than the nicotine reason. I mean, going to why I think the nicotine reason is less likely. I mean the nicotine strength thing is a little bit of a red herring in understanding this. Just because a nicotine liquid is stronger doesn't mean you consume more nicotine. It means you consume less liquid. It's a little bit

like whiskey. You know, you don't consume whiskey by the point you consume it by a few millilitres at a time. It's not something that you glugged down like you would glug down beer. And it's the same kind of thing with stronger vaping liquids. So the dual product uses a strong liquid, but the user will get about the same nicotine that some body using a weak liquid in a

much larger device would use. Well, some people have come back and you say, Okay, I buy your argument about the benefits for adults, but why not just make it available by prescription. That will help keep it out of here as kids and adults can still get it just as easily as they get other drugs that doctors prescribed very easily. Why not? Why not prescription only? The reason is that if you're dealing with a population of smokers, you're trying to get them to do something that they

may be reluctant to try. If you start to put barriers in the way of people accessing the alternatives, or if you misunderstand their drive to use these products, then you will get a much lower rate of switching. So there are really two kind of competing models for quitting smoking.

One is this sort of medical route in which you get a nicotine replacement therapy or a pharmaceutical prescription only preparation like verenically or be appropriate, and the idea of those is to manage withdrawal and craving while you move from smoking to abstinence. The e cigarette public health model works in a completely different way. It works by replacing one pleasure smoking with another pleasure, vaping that has many

of the same characteristics. So it's branded, It comes in flavors, it has a nicotine delivery that you like, It has throat sensation, hands and mouth movement, It forms part of behavioral rituals, and so on. It replaces many things that people get from smoking, but with a lot lower risk.

So it's an alternative consumer proposition. Now, if you suddenly try to take that and cram it into the medical box, you're breaking the basic appeal that that proposition has to smokers who do not always see themselves as sick and in need of treatment the healthcare system. Okay, so Clive, the people selling these cigarettes right are ultimately gonna be Big Tobacco. They didn't start it right. It got started as something that was almost challenging Big tobacco, and the

whole vaping world was anti big tobacco. But when big tobacco saw the opportunities and maybe saw the writing on the wall, and what I also hear from people is so okay, cigarette markets are declining, Big tobacco is trying to save its ask by getting people addicted to something new. They are now going to be doing ever more sophisticated east cigarette and other types of devices. They're going to be hooking a whole new generation to a new set

of nicotine products that they'll be making money on. And in the same way that decades ago Big Tobacco experiment it would how to make cigarettes more addictive. Now they're gonna be trying to figure out how to make these e cigarettes more addictive so that a young generation starts like they did with cigarettes, you know, decade and generations ago, and they become lifelong consumers with a product debt is still of you know, safer than cigarettes, but we don't

know how much safer. So Big Tobacco is a burden that all of us who work on the public health side of this have to contend with. They worked tirelessly to acquire a truly dreadful reputation over smoking and disease, and they deserve their pariah status, and their involvement in

this makes things much more difficult. Ironically, I think in a way that cartel involvement in in the drug trade hasn't actually been a barrier to harm reduction, and may be wrong about that, but I feel that the salience of Big Tobacco in the nicotine and harm reduction debate actually has been very negative. But there's not much they

can do about that. Their incentives are to go where the consumer goes, and if the consumer is switching their preferences for nicotine, you from smoking to vaping too heated tobacco products to other noncombustible products. Then that is where the tobacco companies will go. And I think what we're seeing is that they will evolve, and they are. This is happening already. They are evolving into nicotine companies and

to varying degrees. And the companies are not monolithic. There isn't really a big tobacco They're all different and they all compete with each other, but to varying degrees. The companies are trying themselves to make a transition from combustible to noncombustible products. So Philip Morris International, biggest company in the world outside China, I think, now has something like twenty three percent of its net revenue from non smoked products, up from you know, a tiny fraction in around point

one percent in two thousand and fifteen. So those companies are undergoing a transition, and that is base sickly a good thing. It is good that they are trying and hopefully increasingly driven out of the merchant of death business. The more that we can encourage them to do that, the less heavily their footprints will tread on global mortality. That would be a good outcome. We get back to sort of fundamentals here, What are we actually dealing with.

Are we dealing with something that would simply go away if the tobacco companies went away, Well, I don't think we are. I think nicotine is amongst the legal recreational drugs that have proved popular in society, had been popular for you know, many centuries, and I think in trying to sort of wish away nicotine us, we're making some of the same mistakes that the sort of abstinence only

crowd in drug policy have made. It's much better to work with the assumption that people will wish to use these drugs and in the case of nicotine, is a relatively benign drug, and try to make arrangements so that they can be used safely with some sort of accountability, quality control, redress, taxation, and regulated management of the risks and the noncombustible products allow us to do that and create a platform I think for people who want to

use nicotine for the foreseeable future, in which the tobacco companies are bound to play some sort of role. But

that's a good thing. They have an enormous reach, and if they manage to convert most of their customers, we'd see the smoking disease epidemic fade away pretty quickly, and it kindly seems to me there's the dynamic you wide is that you wid startup companies, very disruptive companies like Jewel wise or if you think about like Tesla wise with respect to electric vehicles, right, that you want these independent companies who are committed to taking over the world

selling their base sickly safer product to be challenging the traditional companies that are selling their more dangerous product. And then you want the big tobacco companies are the same thing with the big auto companies. You want them feeling so challenged that they see no choice except to move

in that direction as well. Yet, at the same time, if it's left just up to big tobacco, if they're taking over the whole East cigarette and harm reduction product market, I mean big tobacco, their bottom line is the shareholder is profits. Right, So even when they say they're committed to moving the harmonduction direction, even when they're doing stuff to do that, they still may not wanted to move too quickly in that direction because that might undermine their profits.

They would seem to have an interest in moderating the transition because cigarettes are immensely profitable to them, more than the East cigarettes are at this point. So I mean the question is, how does one incentivize the big tobacco companies to move as quickly as possible as are there things that government can do or there are other ways to do this? Look Ethan, I agree with that not

very strongly. I think the example of Tesla is a really interesting one because what you have there is, you know, radical innovator, but the worldwide impact of electric vehicles will be felt through whatever Toyota and Volkswagen do, what General Motors and Ford do, not what Tesla does. And so I think that model is exactly right. And we've had that up through the previous decade. The smaller, if you like, insurgent e cigarette companies have changed the game and completely

changed consumer expectations. They've made this a thing, and now the tobacco companies have to follow, and they'll follow by acquisition or by innovation in their own labs. And that is a good dynamic. That is how you get a technology change. That is the process of creative destruction working as intended as new innovations diffused through the user population to obsolete the old technology. The question then is how do you incentivize that process so that it works faster,

better and the change is more rapid and deeper. And again here it's about taking the incentives of all the companies involved and aligning them with transition from high risk to low risk products, both as consumers and producers. And this is one of the frustrations I have. My frustration

is coming over here. It's one of the frustrations I have is that so many people in the public health world seem to be working against that huge amounts of money seemed to be going into slowing this highly desirable creative destruction process from high risk to low risk products.

If you take the situation in the United States, the process for licensing and e cigarette product is massively burdensome, requiring a huge authorizing shan process running to millions of dollars per unit that really only the biggest companies can afford. The FDA itself is creating a dynamic that will restore the tobacco industry oligopoly in the e cigarette market, replicating

the oligopoly it has in the cigarette market. We see who going around the world applauding every time a developing country outright bands e cigarettes, effectively introducing a regulatory protection of the incumbent cigarette trade. I mean, nothing could be more mad than that. Yet, in theory, the top public health body in the world, that's its favored policy prohibit

e cigarettes outright leave the cigarette trade relatively untouched. Yeah. Well, Clive, I think we're getting to the issue of the elephant in the room here, which is a fellow named Michael Bloomberg. You know, my distinguished mayor for many years in the Ark City. But here's a guy who's what maybe the tenth wealthiest guy in the world, you know, fifties sixty

billion dollars a year. He put a lot of money into trying to get people to quit smoking, which I think we can agree was a very good thing for him. But he's now spending, you know, committed hundreds of billions

of dollars to banning vaping. And then I look deeper and you see that he's given a hundred million dollars I think, to the w h L World Health Organizations Foundation, and he's given a hundred million dollars to the CDC, the foundation of the Center for Disease Control, and he's funding all these groups that we're talking about, right, So it seems to me there's a powerful, corrupting thing going on here with somebody who's been very committed in other

areas to public health and even to harm reduction, but who has a kind of ideological prohibitionist abstinence view here. And I'm wondering if there's you know, how far does this influence go. I mean, you look at the medical societies, You're the ones, the cancer societies, the heart associations, I mean, even these organizations that should be leading advocates for protecting health buying into the anti harmonuction thing. Is all that just about this money? Or is it? I mean, what

is it? M So Look, I mean Mr Bloomberg, I don't doubt for one minute his intentions and his motivations are good. I think he's trying to do good in the world. He's trying to spend his fortune in a way that improves things, and I think everyone should acknowledge that he's done a lot of really good work. But look, he's a financial services billionaire. He is not well connected with public health or with the lived experience of people

who live in poverty and various forms of disadvantage. He doesn't know what it's like to be a smoker or a vapor and yet he's a kind of instinct player. He is putting an immense amount of money into this field, but matched by kind of billionaire confidence that what he's doing is right and that the problem is that not everything Mr Bloomberg does do is right or has the

effects that he expects it to have. You know, I just say one example recently, so he has put a hundred and sixty million dollars into campaigning to ban e cigarette flavors in the United States. Now, in advocacy terms, that is a gigantic sum of money to try and secure a policy objective that is sort of relatively obscure

in kind of most people's thinking. Yet, we have just had some early data in from San Francisco where they did introduce a ban on e cigarette flavors, and you know what happened, Youth smoking when up When surrounding districts that are not bandy cigarette flavors, smoking rate continued to track downwards. So there we have the example of an

unintended consequence arising. We can't say for certain about cause and effect, but it appears very strong Lee related that we had a policy measure favored by Mr Bloomberg, and look, it's turned out to have an unintended consequences that causes the public health impact be worse, not better as a

result of his investment. Now, Bloomberg also told The New York Times during his run for the presidency that he thought that vaping should be outright prohibited and that it would be good if the future president of the United States did that. Now, prohibition comes with just the worst kind of possible unintended consequences. Yet he is promoting these

kind of policies around the world. He's put in over a billion dollars worldwide inter campaigning, including into the World Health Organization, including into the World Bank, including into a large network of supposedly civil society organizations who really are just kind of AstroTurf for him, all pushing these kind of ideas, and they create a kind of out call

it a sort of Bloomberg anti vaping propaganda complex. It's a gigantic enterprise funded by enormous quantities of money and ideological commitment to actually marginalizing these products and marginalizing the harm reduction concept in favor of his own preferred package of measures which he thinks will lead to total abstinence.

So he's an abstinence only campaigner in a world of public health that generally favors harm reduction in all other areas, whether it's HIV, sexual health, drugs, alcohol, and sort on, we tend to favor harm reduction and not him in

this area. And he is really causing an immense amount of trouble, and his legacy, I'm afraid to say, will be dominated I think by a reanalysis at some point in the future that no one did more to protect the incumbent cigarette trade than he did, and he will bear responsibility for hundreds of thousands, maybe millions of deaths as a result. Yeah, no, I mean claim. I agree.

It's a tragedy because you know, we look at the evil work of big Tobacco over all those years and how many people have died, and now to see Bloomberg's philanthropic money basically, you know, standing in the way of what would be an effective public health campaign, apparently because he's just surrounded himself with the wrong people in this area. Let's take a break here and go to an ad When you look at the Heart Association the longer associated.

I mean, why are these medical associations, which should be focused on the science and the evidence, why aren't they getting much more behind tobacco harm reduction. Either. It's a great question, and actually it's the question I'm most often asked because a lot of people are like, you know, can't understand why, why why can't everyone just get behind this and will have dealt with smoking in a couple of decades, it will be gone completely from the world,

you know, or it will be highly marginalized. I think there's lots of reasons behind it. I think there is a strong gut instinct of disgust about smoking that came from people who were, you know, perhaps non smokers rights campaigners, the fact that people had to grow up in smoky environments and so on, and I think those people, their instinct, their gut visceral instinct, is that they just want the

whole thing gone. Then I think there's the medical establishment view, which is, look, we know best, you should give up this habit using a medicalized approach that we favor. You are our patient, you are in treatment, do what we tell you, and you will recover and be cured. Unfortunately, that model doesn't really work very well for most nicotine uses. Most of the time, the success rates of that are

extremely low. And medically you're talking about things like nicotine patches and arms and some of the parmaceutical products to help people quit. Yeah, I think there's a medicalized model behind this that says, oh, look, this is tobacco use disorder. It's a psychiatric ailment. We will cure you using pharmaceuticals that will deal with your withdrawal and cravings, and we will get you from being a user to being abstinent.

That's a model. It's not one that says, actually, we're cool with nicotine use, just don't smoke because that's what's going to give you cancer, heart disease and respiratory ailments. That is not the way medical people think about this, and they've they've aligned around that. But I think I think there's even bigger reasons for this. So and I

was part of this. I as you said in the introduction, I used to run Action on Smoking and Health in the UK in the late nineties to early two thousands, and basically we built a massive fighting machine for fighting big tobacco and fighting the cigarette trade and smoking and we were all, you know, basically in the Gray Tobacco Wars, and it was, you know, a big conflict with a big,

bad industry. The trouble is that machine still exists, and I think what it's done is, rather than say, look, there's no more war to fight, it's sort of swiveled its gun turrets towards the new thing and has now started blasting away because that's what it does. That's what you do in the anti tobacco, anti smoking movement. You go into battle against big businesses and behaviors that you

kind of disapprove with. And so there's a kind of institutional inertia that sort of sits behind this in the same way that there isn't a kind of caffeine control industry or the alcohol control industry is much smaller and weaker because it doesn't fight the same kind of battles that we used to fight against big tobacco. And then,

I don't know, money plays a role. I mean, many of those organizations that you mentioned, you know, Lung Foundation, Heart Foundation, they have taken significant money from Bloomberg for joining in this anti vaping effort. So you can't rule out the effects of money. You also see that happening in academia. Food and Drug administration and National Institutes for Health are a huge source of funding for research. But the kind of research they want is research that finds problems,

that finds reasons to regulate, that finds bads. They are much better at research that develops a problem than research that acknowledges or investigates an opportunity. You just don't see research looking to kind of round out and quantify the opportunities at anything like the scale or with anything like

the financial backing that you see form from problem orientated research. Clive, I'll tell you when I started getting involved in this area a few years ago, what really struck me was that I was meeting these wonderful researchers, distinguished academics who are pro heart reduction, and they reminded me a lot of the people I had met in the academic world who were doing the work on harm reduction and needle exchange and over those prevention in the eighties, nineties and

and adds. I mean, basically, when people who were focused on how do we most effectively reduce the harms associated with the consumption of tobacco in our society, and that was the focus balancing these the kids, these the adults,

you name it. And then what I saw on the other side was this kind of massive establishment fronted with government money and Bloomberg money, who also wanted to reduce the harms of tobacco, but who diverged a because where they had started off being just anti smoking, now they had adopted a sort of ideological anti all nicotine approach,

a kind of abstinence only approach. That Secondly, it seemed like they were so traumatized by their multi decade battle with big tobacco that basically driving a stake through the heart of big tobacco seemed to be a greater objective for them than was adopting a really comprehend of harm reduction approach. And now, as you say, they have the money to fight this battle, But I mean, is that the way the world looks to you as well? Honest? Yes, it does actually, and I think I think it's a

very good assessment of the current situation. It's harder and harder for them to maintain the argument about harm reduction in the nicotine and smoking area. Evidence is coming in all the time that vaping is displacing smoking with the net public health benefit. And you know, I'm sure that evidence will get stronger and stronger over time. There's no real doubt about it. There's multiple strands of evidence that

confirm that that is the case. So what we've seen is the people who oppose these developments, the anti harm reduction abstinence only groups have gravitated to two basic sets of arguments. One is kids and the vulnerability of kids to nicotine, in which I think we've discussed that quite a bit, but I think you have to just take a much more nuanced view of youth th behaviors to work your way through that. And the second, and you

hear this getting louder and louder, is the tobacco industry. Essentially, tobacco industry comes with such terrible reputational baggage they form an almost perfect enemy. And it's almost as if you can dismiss an entire public health concept like tobacco harm reduction just by mentioning the word tobacco industry or suggesting that the tobacco industry may benefit from selling the products

that are harm reduced, low risk alternatives to smoking. That almost for some people ends the argument cligant Before COVID came along, right, The sort of epidemic before the pandemic was the epidemic of vaping, right. It was on the headlines and TV shows and magazine covers in the United States, And then towards the end of that in mid we saw this whole thing about, Oh my god, people are landing up in the hospital, right and their lungs are

getting destroyed. And the CDC, the usider Disease Control labeled the disease and E cigarette and vaping E Valley. I can't remember what a L stands for, but they labeled it that thing. Now, it turned out, of course, that virtually the entire thing was not about nicotine vaping. It was about illegally produced th HC vape cartridges, which some knuckleheads were producing and mixing with vitamin E oil because that way they could, you know, basically cut their costs

and make more profit. And what struck me about it was the evidence that this was about tainted, illegal th HC vape cartridges and not about the cigarettes seemed incredibly apparent from early on. Yet health authorities and political officials and even the Center of Disease Control kept obscuring that fact. I mean, what was going on there. I think this was an information sort of black operation. Basically, you're quite right.

There was a cause, you know, maybe around three thousand hospitalizations, over sixty deaths, very very severe acute respiratory disorders, and therefore there was a massive concern about it. But all the evidence, and it's not just even some of all the evidence is clear. This arise from the addition of a cutting agent to th HC vaping oils. Cutting agent was vitamin e acetate. It's used to dilute the oil for economic reasons, a normal sort of you know, drug

production kind of economics. It was done in the illicit market by you know, the criminals that produce and market these products. Had absolutely nothing whatsoever to do with vaping nicotine. There's no link at all. You can't add that additive to a nicotine vape. It just it's not soluble in the liquid, and there is no economic purpose to doing it whatsoever. So, having defined the cause, and I agree with you, this outbreak kind of came to light in

probably around June two thousand and nineteen. By August two thousand and nine, ten, it was pretty clear what the problem was. But I would say that CDC, in particular, were maintaining a kind of ambiguity about the cause which

persists to today. I mean, they've never said, which they should definitively, that nicotine vaping liquids were nothing to do with this, And it's just not possible that there would have been a separate cause in the nicotine vaping supply chain that happened in the same geography in the United States and exactly the same time mid two thousand and nineteen to early two thousand and twenty, with exactly the same symptoms, but was caused by something else. Now, there

was some confusion because some people denied using THC. What a surprise. If you admit to using cannabis, you can get in trouble with your employer, with the police, with your college, with your school, and with your parents. So unsurprisingly, some people said no, no, no, no, I was never vaping th HC, and therefore that was used to maintain the myth that this may have been something to do

with nicotine vaping. But the fact that it never occurred anywhere else, the fact that the cause in the illicit th HC vaping supply chain is clear, tells us what we need to know, and that incident is over because not even criminals want to actually kill their customers. So as soon it was clear what was causing it, they stopped doing it, stopped using that thickener, the supply chain emptied,

and the problem tailed out in early two thousand. Hasn't really been seen since except the odd thing that's been lingering in somebody's cupboard. It just seemed like an opportunity for the anti harm reduction folks, right, and they really took it right. I mean, it was a myth. They propagated and perpetuated, essentially a lie, even though they knew better.

They promoted misinformation. They did this from the Center for Disease Control, and they said, well, if we're not being so successful of discouraging them with whatever truth we have on our side, let's take advantage of a myth and a popular fear and run with that. And I think, you know, I haven't seen the latest surveys, client, but I think probably in the jority of Americans still believe that that long damage, that long problems resulted from nicotine vaping.

It just hasn't been corrected. No, I think you're right. I mean that that has created the perception that these products are highly dangerous, and there's been good measurements on how risk perception shifted in the United States, and actually it flows across the Atlantic of course, so we get this in the UK as well. People think these products are much more dangerous than they are and that is

one reason why. And the fact that CDC has never definitively sort of crushed that idea, which they could do if they wanted to, the fact that they have let it roll and let it run tells you that they have found it useful as part of their anti vaping campaign. The problem is the unintended consequences of making people fear vaping is that you get relapse from vaping to smoking, and you get fewer smokers willing to switch from smoking

into vaping. So you know, the idea that that was a good thing to do is actually an incredibly a responsible thing to do. And then also for the people who are used as an illicit th HC vapes, diffusing the problem across nicotine vaping, th HC vaping, any kind of vaping has not given the sharp public health message which should be watched out when you buy an illicit th HC vape you know, that message was lost as well, so there was a harm associated with not warning vaping

cannabis users properly about the danger. So the whole thing is grossly irresponsible in my opinion, and it's one of the reasons why it's effectively pans out as another form of defense of the cigarette trade. It gives people the reason to say no, no, no, no, I'm going to stick with this. And one final point on this ethan if if you don't mind, it's also been conflated with another lung related thing, which is popcorn lung. So people

have this big fuzzy idea. You know, normal people don't get into the detail or read papers on this, quite reasonably, but they've heard about something called popcorn lung being associated with vaping, which it isn't. It's associated with one additive use sometimes in vaping when you're exposed to massive levels of it. But you've heard about popcorn lung, and then you hear that there's people dropping dead from vaping because of this VALI thing. Put two and two together and go,

I'm not even going to take that risk. I'll stick with the lung disease that I know and like, which is cigarettes. Yeah, you know, I guess what it comes down to, Clive, is we think about it. There's over a billion people still smoking cigarettes or other combustible tobacco products around the world. There's thirty five to forty million smokers in the US, which is roughly equal to the entire population of California, or almost the same as the

entire population of black people in America. And if all of them were to suddenly switch to vaping or using these oral products or heated products, it would probably be one of the greatest public health advances in human history. And it seems that what stands in the way is just the same sorts of ignorance and foolishness and self interest that drove the war on drugs for many years. Would you agree with my formulation that way? I agree

with you. I think the more you look at this, the more it has the feeling of war on drugs mentality. We we used to be in a battle against harm. I mean, I got into the business because you know, it was about cancer, about heart disease, about people living in utter misery with emphysema, and so on. My father died smoking related disease associated with heart failure. There were

real public health reasons to be involved. Now, as we're beginning to solve that problem with these noncombustible products, we're seeing a big shift to a war on drugs mentality, which is that we don't think people should use the drug nicotine. Now, that's a very different public health proposition, and it's not one that I think we should be pursuing. I think we should be pursuing reduction of harm, aerial disease outcomes, a life expectancy outcomes, and not worrying ourselves

about nicotine so much. I mean, I'm not recommending nicotine use, but people are going to use it in the same way that they use alcohol. Not recommending that either, but people do like it. People do use it. Question is can you keep the harm under control? Yeah, claud you know, I think also for me growing up, my basic exposure to addiction was seeing my dad's relationship to cigarettes center food, and he died of a massive heart attack when he

was fifty eight as a result. I probably he can't prove it, but probably of his packet day cigarette habit and his obesity. And I oftentimes have thought in recent years that my dad would have been a good candidate to have switched to an east cigarette or a heated device, and it might have made the difference in his living longer. Sounds like your story somewhat similar. I think exactly the same about my father. He would have loved the innovation.

He'd have been an earlier adopter, and had he done that early enough in his smoking, rarely have these things been availably still be alive too. Now I'm convinced of it. Yeah, I mean I looked at a very powerful politician like Senator Durbin who said that he hates vaping and the cigarettes because his parents died from smoke gay, and I'm thinking, why didn't he come down where we are? He's missing the point. Yeah, So, Clive, you know I should say at the end, it is that you really are one

of my heroes here. I mean, seeing the extraordinary amount of work that you pump out and the ways that you're engaging with the World Health Organization, the f d A and all folks and covering the literature and reading it is basically a one man operation. So I just hope you're going to keep doing this and keep doing it until this battle is one. Um. You know, I think we both know that sometimes these battles can feel quixotic.

But I'm incredibly grateful for the work you're doing and also for taking the time to have this conversation with me, So thank you very much. Thank you, Ethan. I wish it wasn't necessary, It shouldn't be necessary, but unfortunately is. Psychoactive is the production of I Heart Radio and Protozoa pic Shirts. It's hosted by me Ethan Naedelman. It's produced

by Katcha Kumkova and Ben Cabrick. The executive producers are Dylan Golden, Ari Handel, Elizabeth Geesus and Darren Aronovski for Protozoa Pictures, Alice Williams and Matt Frederick for I Heart Radio and me Ethan Nadelman. Our music is by Ari Belusian and a special thanks to a Vivit Brio, Sef Bianca Grimshaw and Robert Beatty. If you'd like to share your own stories, comments, or ideas, please leave us a message at eight three three seven seven nine sixty. That's

one eight three three psycho zero. You can also email us as Psychoactive at Protozoa dot com or find me on Twitter at Ethan Nadelman. And if you couldn't keep track of all this, find the information in the show notes. Next week we'll be talking with Larry Krasner. He's the District Attorney of philadel Fia and playing a pioneering role among the progressive prosecutors who are reshaping the face of

criminal justice in American cities. You think most people, I mean most of the cops and prosecutors and judges in Philadelphia would now vote for legalizing marijuana. Are we going to count the retired ones. If you count the retired ones, I would say no, no, But the current ones probably is. I think that there are subgroups, maybe younger officers, probably

officers of color, who would vote for it. I think overall they would vote against it, And to be honest, they have a specific financial interest in voting against it because they don't simply get paid to arrest people. They get overtime, and they get a lot of overtime for going to court to testify when they're not on shift. I mean, honestly, I think if they could arrest people for blue shirts. I'm wearing a blue shirt today, some of them would be mercenario up to say, hey, it

sounds like a good plan. Let's arrest people for blue shirts. I want a beach house and they would do it. Subscribe to Cycleactive now see it, don't miss it.