After the Spending Review: Public Health in a smaller state?

“This Spending Review finishes the job of reforming the public health system, delivering average annual real-terms savings of 3.9% over the next 5 years. Across the country, councils have already begun to develop new ways to deliver public health, showing that it is possible to deliver better health for local people and also better value for the taxpayer, but there is more to be done. Councils can seek to deliver efficiencies in this area, and can learn from best practice. So it is right that as the government eliminates the deficit, all funding is spent in the best way possible. Public Health England will continue to support local authorities in this process.”

(Source: https://www.gov.uk/government/publications/spending-review-and-autumn-statement-2015-documents/spending-review-and-autumn-statement-2015 )

 

So the Spending Review has happened. In some ways we all got what would happen wrong, the Chancellor surprised everyone, while disappointing many and setting us all wondering. Some of the surprises were pleasant, some less so.

There were some good things. Tax credits, and with it the public health benefits of keeping some families out of poverty is something I am grateful for. The extra money for mental health too, is to be welcomed, assuming it turns out to be real money and not previously announced. We’re still in the process of trying to decipher what’s new, what’s previously announced and what the implications are. But it could have been a great deal worse.

I’m not underplaying how difficult this will be, I’m just saying that it is mixed and there are some things to welcome, while the public health cuts still seem to run counter to an expressed policy aim in Government of saving cost to the public purse by stopping people needing public services.

The Local Government Association’s useful document Prevention: A Shared Commitment (1) and Creating a Better Care System (2) strike me as two major opportunities to assist that expressed policy, which the Spending Review has missed. It seems that local authorities facing ever less money will be forced to turn to demand reduction, prevention and early intervention to make budgets balance. That will require good articulation of what will deliver those reductions in demand and need, a point I will return to.

The Public Health Budget

My feeling on the Public Health cuts is that we should acknowledge that it could have been much worse; and we should recognise that, even though it will be tough and challenging and the cuts will have an adverse impact on the health of at least some of the population. That in no way minimises the challenge or the harm.

The Public Health budget for England will be reduced by 3.9% on average until the end of the current Parliament. Duncan Selbie, CEO of Public Health England stated today in a letter to Chief Executives and Directors of Public Health in local government that on top of the 6.2% cut (the £200million) in the current financial year there will be cuts of 2.2% in 2016-17, 2.5% in 2017-18, 2.6% in each of the two years after that and then flat cash in 2020-21. By this time the ring-fence will have gone anyway and public health will be funded from Business Rates.

Public Health in context of Local Government Finance

The LGA estimates that overall council budgets will fall by 24% by 20-21. The Chancellor has allowed councils to protect social care, at the expense of a 2% increase in council tax. This may raise decent amounts in some areas, but in some smaller and northern authorities it may raise little. The move to allowing councils to retain business rates is also nothing like as simple as it seems, and we will need to be alert to the issues for the whole council as well as Public Health in this move.

For some time Social Care and Public Health have been noisy, wicked and troublesome problems in political terms. It’s worthwhile considering this when we think about the Chancellor saying to local councils in England that they can pay for Social Care by a 2% precept on council tax  and Public Health can go into business rates from 2018. Depending on which way you look at it either the Chancellor has given local areas total control or he has put the solution – and the blame – for two noisy aspects of the local government portfolio away from Whitehall. If you can’t raise enough money to prioritise and pay for social care and public health through these new powers (despite the inequalities in how much different areas are capable of raising because of their taxpayer base), well, central government can’t be blamed. It’s those local councils not doing what they should.

Moreover, the debates on the target per-capita of funding and the formula for it may also be a casualty of this new finance shift. If public health funding goes into business rates, the idea of getting to a target for public health funding may go into the local, not the national realm. If councils don’t want to fund their public health functions to target, that’s their choice, the rhetoric might run, and not a matter for central government. The electorate can make its views known at the ballot box. The government’s statement that this “Spending Review finishes the job of reforming the public health system” may well turn out to have many more layers of meaning than just mainstreaming public health financially as well as organizationally into local government.

Cut to spend: the wrong approach to Public Health funding

There are those who think Public Health is nanny state, telling people to “behave themselves” or who feel that public health is purely about education. They may not see some of the things which Public Health does, thinking it’s all about campaigns on diet or alcohol. This is partly our job to let people see what we do.

Let’s be clear, the evidence that well chosen and well prioritised public health services save money for the state while preventing worse outcomes for the person is strong, clear and consistent (3,4). Investing in well chosen public health is an investment to save. Cutting those is a cut which will serve only to cost the taxpayer more later. Yes, there are some things in public health where one may wonder “why are they doing that?” but from smoking cessation through weight management to sexual health and drug and alcohol addiction treatment the evidence of effectiveness and evidence of return on investment is solid. (3,4)

So what would happen if we cut public health services?

  • If we cut health visitors:
    • Essential checks on children and young people’s development would not happen, missing developmental problems which disable or limit children in later life
    • Lack of vaccination cover may mean children develop avoidable illness, with complications of measles, mumps or rubella resulting in potentially serious disability
  • If we cut school nurses:
    • we may miss the early detection of hearing and sight problems in children at school, with significant impact on their development and health
    • Children who would get early help for self-harm or mental health issues may get worse before they get better
  • If we cut sexual health or contraception
    • People may not access contraception and as a consequence unwanted pregnancies and abortions, with cost to the state (benefits, nhs treatment etc) will go up (5)
    • People with sexually transmitted infections may not seek treatment with serious consequences for untreated infections, and outbreaks
    • The rise of antibiotic resistant sexual infections will continue, meaning some infections will become ever more costly to treat. The recent outbreak in Northern England by some estimates cost up to fifteen times the cost of first line treatment when you add all the costs together. How do we stop syphilis and other STIs becoming killers once more? What if Lymphogranuloma venereum – a vicious and serious form of chlamydia – becomes antibiotic resistant?
  • If we cut weight management
    • Diabetes cases and cases of avoidable joint and musculoskeletal problems, needing more expensive health and social care as a result, will continue to rise
    • Diabetes will continue to rise
  • If we cut physical activity
    • Older people who would otherwise use physical activity services will be more at risk of deteriorating muscle condition, and more prone to fall. A single fall can cost over £42,000 in health and social care cost
    • The benefits of physical activity for long term conditions and mental health may be lost, with increased cost from medications and other treatments
  • If we cut health checks
    • Undiagnosed diabetes , heart disease and risk factors for stroke in some people with high risk will mean avoidable emergency hospital admissions and even death
  • If we cut drug and alcohol services
    • The significant success of methadone programmes in reducing acquisitive crime could be lost, with increased crime and more drug related deaths
    • Those drug and alcohol services which are working well in getting people into recovery, off benefits and into work may stall. Meaning people remain dependent on benefits and services when they could be working and contributing to the economy
    • We will see increasing and very costly numbers of people with Hepatitis C
  • If we cut smoking cessation services
    • People with mental health problems, who make up 64% of all tobacco consumption in England, will continue to smoke and die earlier than the rest of the population, and will continue, on average,to need up to a third more medication because of smoking, costing us more money on drugs and care
    • We avoid the benefit of moving people who have been very resistant to giving up smoking to things like e-cigarettes. This means far from seizing the opportunities presented by ecigarettes we end up cutting smoking cessation services AND people who keep smoking tobacco will still cost us large sums in health treatment. How to snatch defeat from the jaws of victory.
    • Routine and manual workers and some other populations will continue to die earlier

I also fear for what this will do to antibiotic resistant disease. We are seeing more infections resist even our strongest and most costly antibiotics of last resort.  There are no new drugs coming down the pipeline for this anytime soon. It is serious.  We are already reaping the cost of rising antibiotic resistant TB – a condition that cost £750 in drugs to treat can now cost up to and over £7,400 to treat, and in a few cases it hasn’t been treatable. People have died.  Antibiotic resistance is real.   I really am not being melodramatic. There is a real prospect this may happen.

Some of you may disagree with me, and some of you I know think Public Health should be much smaller than it is, because you tell me on social media. But there is a moral case to try to keep people healthy as well as an economic case. The cuts mean that there are some areas of the business public health teams are currently in that we may need to get out of. How do we do that without harming people, and without adding to the burden of health faced by those already most burdened by ill-health and its determinants?  I’m not against saving money, but we should not seek to save money in ways which will end up costing more. That’s not just bad economic sense, it’s immoral.

And I still think as I blogged some months ago there are many other areas which this spending review seems not to have touched where savings would be easier to make than these (6),  would be bigger in amount in the short and the long term, would be sustainable and would not just create cost elsewhere in the system through false economy.

The challenges for public health

But now is not the time for despondency. Those of us working in Public Health – elected or appointed – face the challenge of trying to sustain what we can of the public health system (the hard end of public health) with retaining that portfolio of services which promotes and protects the health of the public most equitably while doing least harm. This is a test of our mettle like never before.

But there is another, and deeper, challenge. It seems to me that we are at the beginning of another journey which is at least an implicit political choice by government – we are moving to a much smaller state after nearly twenty years of comparative expansion in the public sector.

This second, and bigger, challenge for public health will be how we help public services become more preventive, shifting people to not needing services as much as possible, so when people do need services we can intervene and support. This will test and stretch the public sector to its limits. It is something we in public health must rise to.

There is, too, a third challenge, the enduring fiscal challenge which is the NHS. But more about that below.

The size and shape of the state – a deeper signal amidst the noise?

The signal the Spending Review sends is not just one about repaying the deficit. There seems to be a conscious choice to reduce the size of the State, as the diagram below shows. In a state where most people learn to be independent and can look after themselves, that’s not necessarily a bad thing, because the state can focus on enabling people, and on helping those who really need it, and there will always be those who need it.

 

spend as portion of GDP

 

(Source: http://www.ukpublicspending.co.uk/spending_chart_1970_2016UKp_15c1li011lcn_F0t_UK_Public_Spending_As_Percent_Of_GDP)

 

Public Health focused services could have a natural role to play in a society which is like this, supporting people get the best and healthiest start in life and ensuring the most vulnerable and those who bear the worst burden of ill-health get best opportunity for best health achievable for them. We face a challenge to articulate the preventive and protective role of public health in a smaller state. Our time starts now. And we are not there yet.

A third challenge: whither healthcare in a shrinking state?

But if the size of the state is shrinking overall, what about the NHS? The Spending Review not only protects NHS spending but increases it. In England the state is putting £8 billion more in, and as a portion of GDP spending on health care is increasing in the UK and in England. Our spend on healthcare by proportion of GDP is nowhere near that of the USA (18% and rising.) But it isn’t insignificant, by any means.

 

healthcare percent gdp

 

(Source: http://www.ukpublicspending.co.uk/spending_chart_1994_2014UKp_15c1li111lcn_10t )

Are we really getting value for this? More spend doesn’t equal more quality. The US was recently ranked last of eleven countries for health outcomes despite its spend. The big lesson here is if we fail to reduce inequalities in access and outcomes it won’t matter how much money we put in people will die avoidably. (7) The UK in 2015 was ranked 28th out of 30 countries for our health system by the OECD (8). We have a lot of room for improvement in what we do, and pouring more money in is not in and of itself the answer.

Moreover, if the rest of the state is shrinking overall, that means health care will eat up an increasing share of public spending, which has to be diverted from other areas to feed the demand.

The UK NHS does amazing things, but simply pumping more and more money into the NHS system to inexorably increase the proportion of GDP it consumes, without concomitant rise in health outcomes, is not sustainable when a political choice seems to have been made by the Chancellor to shrink the state overall. Why would you not focus on sorting out the system?  Simon Stevens says he wants to do just that.

I fully support the ambition of Simon Stevens for prevention in the Five Year Forward View. But this requires a systematic application of public health skills across the system, and not just pumping more money into the NHS. Equally, the answer is not to run new prevention programmes in an entirely NHS driven silo because someone has decided intervention fidelity conquers all other considerations while local existing prevention infrastructure like physical activity infrastructure is left to wither. That will waste money needlessly.

It strikes me that there are three opportunities here for public health:

  1. The opportunity is to really get stuck into the opportunities for prevention across the system of local services, especially where we might be able to prevent the fast impending tsunami of cost from long term conditions and avoidable disability coming at social care and the NHS. No amount of money pumped into the NHS will ever be enough unless we do it differently and preventively. It’s time to turn policy talk into service reality.
  2. That, unfortunately, requires us to work in an area where the evidence for secondary and tertiary prevention is at best lacking, and yet little of our public health science infrastructure seems interested in working on it. But it is an area of pressing need. How do we as public health specialists – in academia as well as in commissioning and provider organisations – articulate to the NHS, social care, housing and other local government functions what are promising routes to save costs, avoid disability and prevent early death in these areas? This could lead to a new impetus in public health science. Because we desparately need it. That means the NIHR School for Public Health Research really needs to rethink its priorities in this new context.
  3. We have an opportunity for a renaissance of service quality public health, and not just what we called healthcare public health. Service quality in social care, childrens services and other areas could benefit from the development and application of public health skills to these challenges. How do we keep people out of hospital? How do we improve primary care to reduce the risk of them needing more healthcare? How do we work as a system across public, commercial and voluntary sectors to keep people healthy, minimise the burden of disease and reduce cost to the state? For example, what could public health do to design a system which reduces the cost to police, probation, housing, benefits, health and social care from adults with very complex issues? This should be the kind of place where public health could excel. IPPR produced a report on this earlier this year (9). Hertfordshire launched a programme several months earlier, even before IPPR produced its report (10), and I am excited to be the Sponsor of this. This is where we should be.

The next five years

To lead in Public Health for the next five years is not just about revisioning the footprint of public health services, though that is vital. The opportunity is to renew Public Health from first principles and rise to the challenges above, helping the system respond. We must monitor and make transparent both where we are successful, and where these cuts harm.

I was tense on Tuesday, worried on Wednesday, and troubled on Thursday. It’s Friday…I’m firmly resolved we need to do it differently . Time to get started….who’s with me?

 

References

  1. http://www.local.gov.uk/documents/10180/6869714/Prevention+-+A+Shared+Commitment+(1).pdf/06530655-1a4e-495b-b512-c3cbef5654a6
  2. http://www.local.gov.uk/documents/10180/6869714/Creating+a+better+care+system+June+2015/0692d75a-5c26-4b85-a2b5-9e7dd59b455e
  3. http://jpubhealth.oxfordjournals.org/content/early/2011/09/20/pubmed.fdr075.abstract
  4. http://www.local.gov.uk/documents/10180/11493/Money+well+spent+-+Assessing+the+cost+effectiveness+and+return+on+investment+of+public+service+interventions/25c68e94-ff2c-4938-a41c-32853b4d4a9d
  5. http://www.fpa.org.uk/influencing-sexual-health-policy/unprotected-nation-2015
  6. https://jimmcmanus.wordpress.com/2015/06/11/a-bit-of-thinking-on-saving-the-country-200m-and-much-more/
  7. http://www.commonwealthfund.org/publications/press-releases/2014/jun/us-health-system-ranks-last
  8. http://www.oecd.org/els/health-systems/health-data.htm
  9. http://www.ippr.org/publications/breaking-boundaries-towards-a-troubled-lives-programme
  10. http://resolving-chaos.org/Hertfordshire
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How and why I changed my mind on e-cigarettes

E cigarettes and ending death from tobacco

I want to see an end to the misery, death, disease and disability caused by tobacco. My dad died (a soldier, miner then bus driver) as a result of it, and my grandfather (a farm labourer then miner all his life) too. And there isn’t a day goes by when I don’t miss them both, many years later. People I went to school with (a scottish village full of miners, farm and factory workers) are now disabled by smoking.  And my determination only solidified when I read the 2014 report of the surgeon general on smoking, for the 50th anniversary of the Dolland and Hill study, which said smoking was now firmly implicated in Diabetes.

I now believe, equally firmly, that we have enough evidence to use e-cigarettes as part of this battle, and that those who use e-cigarettes are part of a significant consumer-led social movement which we in public health must use for benefit, without disrupting the good which has been done. This is a sea-change in my views. And there are many people – scientists, colleagues and vapers themselves, who have done me the service of making me listen to them. E cigarettes are much, much safer than tobacco cigarettes. And for many, they are more efficacious than over the counter nicotine replacement therapy.

Earlier this week I had the privilege of listening to some quite amazing scientific and policy speakers at the E-cigarette summit 2015 in London. You can find the agenda here http://www.e-cigarette-summit.com , and in a few days you’ll be able to find this year’s presentations alongside those of previous years in the resources section. Professor Ann McNeill proved to be a formidable and good-humoured chair in keeping a completely stuffed programme to time with great grace and aplomb. (And some speakers had things like 30 or even 50 slides for 15 or 20 minute slots.)

Round up notes of the Summit

I took assiduous notes all the way through, only to find James Dunworth, a blogger at the Ashtray Blog did a much better job than my 21 pages of scribble, and to be honest I’ve printed out his -I think accurate and reasonably impartial – blog and put it in my CPD file. You can find it here http://www.ecigarettedirect.co.uk/ashtray-blog/2015/11/e-cig-summit-round-up-the-vape-debate-continues.html

Declaration of interest

Now I don’t vape, and I don’t smoke. I don’t get paid by anyone outside my day job and although my stop smoking team have had some financial support from pharma in the recent past for seminars the County Council’s explicit and written policy is that policy making on tobacco is ours and we will base that on science, not on the commercial interest of any party who wishes to influence us. My concern is what is good or harmful for the citizens who pay my wages.

On disagreeing respectfully

People of widely differing opinions and views spoke, and the audience was one of the most mixed I have seen at a scientific and policy event like this.  People who use e-cigarettes, retailers, manufacturers, scientists, policymakers, legislators, regulators and others from across the world. Activists and advocates from all sides sat next to the confused and the undecided. And yes, big tobacco was there too, which was very uncomfortable for me, I must confess. So many people packed into a room with a very tight agenda, all being, on the whole, very much more respectful to one another than I have seen sometimes within the public health community when debating this.

I happen to believe you should be able to disagree vehemently without behaving like a churl to those with whom you disagree. Moreover, resorting to ad hominem attacks just undermines you and sullies for everyone the process of discerning what the science says.  And increasingly policymakers feel that those who make ad hominem attacks do so because their arguments and evidence aren’t strong enough to stand up on their own, so it’s fatally counter-productive. Yet it goes on.

I had some good corridor conversations. A number of policymakers who approached me that day had the same dilemma I have just articulated. I also overheard people from completely opposite ends of the spectrum on e-cigarettes say how important this event was. I found that heartening.

What I found somewhat sad was that some of the most vociferous opponents across the globe, and those most prepared to make ad hominem attacks, were absent

My contribution to the event

Anyway, I too was speaking. And for the third time in a fortnight, speaking in the middle of a line up of people whose books and papers I have read assiduously. That’s scary. This week I was in the same day as folk like Robert west and Charlotta Psinger (hello, opposite ends of the scientific position on e-cigarettes.)

I was speaking on the issues and challenges for local Directors of Public Health. You can find my slides here http://www.slideshare.net/jamesgmcmanus/e-cigarettes-challenges-for-local-public-health-systems

My journey of views

Around three years ago I thought e-cigarettes were worrying and probably uncertain as to their safety. This was based on no primary reading but listening to other authority figures who said so. My Head of tobacco control asked me to read the science. So I started. Liz Fisher, my head of tobacco control, is someone whose grasp of the science  I fundamentally respect. (She authored a systematic review on smoking in pregnancy for her Master’s despite being told it was ambitious. She did it.) And her instincts on safety and clinical governance are at the pinnacle of those I know anywhere in health care. Her gentle coaxing of me to read the evidence – not try to make my mind up for me – and her own complete change of mind has influenced me.

Two years ago or so I still heeded the views of people that e-cigarettes were uncertain on safety more than those saying they had benefit and we should be extremely cautious. In 2013 I produced a Guardian blog http://www.theguardian.com/local-government-network/2013/nov/19/debate-needed-safety-e-cigarettes-public-health which either looks like someone sitting on the fence or, as I prefer to think of it (perhaps a little charitably) someone calling for debate which is respectful and serious on the science, not on the animus.

Since then I have paid assiduous attention to the science and to the debate, and have reflected on the ethical and policy challenges of this. Eighteen months ago when my mind had changed to move in favour of e-cigarettes I took part in a debate with other public health professionals where I was asked to speak against. A good intellectual exercise to test my thought process in public. My opposing speaker delivered a sound evidence-based presentation with a scintillating assessment of the evidence in favour of using e-cigarettes. I thought I was roundly trounced. I stood up and shed doubt. What was most chilling was that a supposedly evidence-based profession looked like they all voted with me out of fear that e-cigarettes might turn out to be dangerous, ignoring the accumulation of evidence. And when I asked folk afterwards, some confirmed this. “Do no harm” said one. Good motives, but wrong application.

Double standards of evidence and science

Shocked, I pointed out that we didn’t have the level of science on condoms and safer sex for HIV in the 1980s that we have so quickly for the low risk of e-cigarette harms now. I pointed out that we were using the precautionary principle wrongly. I pointed out that we were expecting a much higher standard of evidence on e-cigarettes than we are on other things (a statement I summed up at the 2015 summit by saying that we don’t have RCTs for bridges but on the whole they stay up). I pointed out that we were operating double standards out of an understandable but wrongly applied fear of harming people in how we assessed evidence and science. A few people in discussion later agreed and changed their minds on e-cigarettes. The desire to do no harm needs to realise that doing nothing in this debate can be harmful.

And so, within the last year, I really have changed my mind. I now feel the benefits of e-cigarettes far outweigh the risks, and that they can have significant benefit for public health. There was such a fundamental change in my views that I found it quite unsettling and wondered whether I had really not reasoned correctly. I went back to my great hero, John Henry Newman, and re-read by way of reflecting on my own journey of mind his Apologia pro vita sua where he recounts the “history of his mind and ideas” to convince others, though mostly himself, of his consistency in principle throughout.

Discussion with colleagues then and since confirms in my mind that when you want to do no harm, when the science has been badly reported, when so many of us have little time to do the reading and updating we want to on other issues, and when so many of us don’t know where to start with a fast moving scientific field, the things which mitigate to keep your views where they are outweigh the resources you can find easily to change.  I know that’s not acceptable, but it’s whats going on. Trusting that our instincts to be evidence based can enable us to make sense of this can be difficult when the science and the landscape is fast moving, and the debate often so fractious.

My views now

As with all things, I will keep chasing the evidence, and will keep our positions under review and if it turns out that there are likely to be worrying harms, we will act. But I do this with all areas of our public health responsibility, why wouldn’t I?  E-cigarettes in this respect are no different. Keep an eye on the evidence as it changes, and develop and build programmes accordingly.

But it seems to me that we have enough of an accumulation of evidence that e-cigarettes are so much safer than tobacco cigarettes, even if we only discuss the levels of emissions of chemicals, that not working with e-cigarettes is to expose people to potentially avoidable harm, and that this is unethical. I feel ethically compelled to find a way of working with e-cigarettes as a public health tool. And the fact that some public health debate has made people – wrongly as the consensus statement says – feel e-cigarettes may even be more harmful than tobacco is something we ought to find shocking and chilling.

I could go on for ever about the things that have changed my mind, but I think we are seeing a paradigm shift happen in the use of tobacco and nicotine with e-cigarettes. This is a consumer led initiative, and this has significant public health potential. In the briefest of summaries here is some of my thinking :

  1. The Precautionary Principle- we have applied this wrongly and too strongly in resisting e cigarettes. It can cut both ways. One interesting read on this is here http://leidenlawblog.nl/articles/an-application-of-the-precautionary-principle-in-e-cigarette-ban Clive Bates has produced an interesting note on the precautionary principle here http://www.clivebates.com/?p=1691 The precautionary principle does not, for me, entail a ban until absolute certainty of safety. We’re not asking for this for coffee, or alcohol, where the evidence of harm is stronger than nicotine or e-cigarettes. We’re in danger of double standards here (see point 6 below.) We seem to want safe, not safer. We don’t want that with sex in the age of HIV. What legitimises us demanding it here?
  2. Rights, choice and equity – our citizens have rights to expect our help and to do this equitably. Respecting their views is important, and we have to work with people where they are, not where we want them to be. That’s the ethos behind harm reduction. Surely if we are engaged actively with this movement we can steer people away from the harm of tobacco and, if it ever happened that e-cigarettes were to have worrying harms attached to them – we could be in there early and react much more quickly.
  3. The Scientific Evidence is that these are much safer than tobacco and that there is some extremely bad science on formaldehyde and other constituents of e-cigarettes being used sloppily to justify restrictions. The ashtray blog’s summary of the summit does a fairly good job of summarising these issues presented at the 2015 summit.
  4. The gateway effect – well, as we heard repeatedly at the Summit, this is just not happening with any force or seriousness. A consensus from very different speakers on this and very different sources of data outside the summit makes this clear.
  5. “E cigarettes will contribute to renormalization of smoking” – there is no real evidence of this from any economy. Apart from anything else, the conception that a device looking more like Dr Who’s electronic screwdriver than a cigarette might renormalize tobacco is ludicrous beyond words and based on poor logic. Voigt’s 2015 paper seems to me to pull apart the uneasy logic behind renormalization. http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2015.302764
  6. Nicotine and harm – the evidence on nicotine being harmful seems clear on first trimester foetal development patchy on one or two other areas, and largely absent anywhere else. In many areas, evidence of nicotine harm in doses delivered by cigarettes or e-cigarettes is just not there. (Many lab studies use massive nicotine doses way beyond what we’d have in reality.) The possibility of uncovering harm in 20 years cannot justify inaction now when the evidence for much greater harm from tobacco is scientifically unassailable. I know absence of evidence is not evidence of absence but  we need to consider whether we are against nicotine caused harm (still paucity of evidence) or nicotine addiction per se. If nicotine addiction is a new public health target then someone please be honest and say so. We seem to adopt harm reduction in other areas, such as opiate addiction. Why are we content to be making an assumed and not explicitly conceptualised perfect which is not evidence-based (nicotine abstinence) the enemy of the good (reduce death, disability and disease from tobacco) in this case? That’s double standards. Some who say people should be able to choose cannabis freely and legally still want to prohibit nicotine, despite the evidence of harm for cannabis (and indeed alcohol) being a good deal stronger than that for nicotine, yet still the subject of fierce debate.
  7. The recent British consensus statement on e-cigarettes was an attempt to speak clearly that e cigarettes are less harmful than tobacco and put some stakes in the shifting sands of the science, consumer activity, policy and ethical debate on this. You can read it here https://www.gov.uk/government/news/e-cigarettes-an-emerging-public-health-consensus .

 

A bit of humility 1: Don’t over medicalise

We in public health are late to the table on this, and sometimes expect people just to shove over and give us respect when we have not really earned it and haven’t really listened much either. Our presence, intended to seize on the public health benefits of e-cigarettes which helping monitor for safety and reduction in harm from them is intended to be beneficial to our populations. But we could disrupt and have unintended consequences. Some countries have taken action which perversely helps big tobacco keep people on cigarettes.

E cigarettes are a consumer choice-led movement, and indeed safety of devices has been responsive from those manufacturers who take their markets seriously, and many specialist retailers see themselves as having an ethical duty to help consumers (it’s good for business) much more so than the lowest common denominator stuff available in, for example, most newsagents. Most pharmacists and newsagents don’t seem to know what they are selling. That isn’t an argument against these devices, it’s an argument for responsible and knowledgeable retailers of quality.

But if we turn these things too much into a medical tool, it could backfire. We could restrict access to what is really a consumer product, and which seems to be helping people away from tobacco largely without public health and the public purse getting involved.

The challenge for us is using them in a way which gets public health benefit, and clinical benefit, without destroying the consumer choice which has done more than anything or anyone to move people off tobacco and onto these devices.

Public Health has no pre-eminence in this debate. It should come to serve the public good, and discern how in doing so it can avoid disrupting the existing benefits created by the market. We need to learn the lessons from activist and community led work on HIV prevention in the 1980s, lest we set progress back.

A bit of humility 2: Scientific Locus

The old concept of locus standi is something we need to look at here. Who has a place from which they are entitled, morally, scientifically or legally, to speak on this issue and command our attention? It seems to me that those scientists actually doing research, and those people who use e-cigarettes, and those people whom governments have charged with properly and duly discerning the science and the evidence, are at the top of the tree here.

The rest of us need to speak with some humility and must do so in a spirit of reading and listening to all sides. A key thing about this debate is that there are many wading in who have no track record of primary or secondary research in this (such as me, for example). And the number of studies I have read where people make conclusions which simply are not justified by their methods is worrying.

So Public Health England in my view is the authentic voice in this of the Public Health system in England because they have the legal mandate to advise.  They commissioned scientists who have done work on this and whose expertise this area is and those commissioned have produced a careful analysis subject to due scrutiny and review. The distasteful response of some to attack the reputations of those involved rather than try to critique the science is shameful and unworthy. And the mooted “peer reviews” by several actors in this debate of the Public Health England review looks to me like a failure to understand locus. It is not the job of any individual or agency to mark the homework of their scientific betters. I remember two public health people asking me at the summit about whether the PHE report needed peer reviewing before they trusted it. “What would you do with anything else?” I asked. “read it and critically appraise it”  came the response. “That’s what we do with everything, right?” I said. We don’t need special additional scrutiny here, just good public health science and method.

A bit of humility 3: Sex, cigs and entrenched views

In answer to a question I recall commenting that this felt like the debate on the Church of England and same sex relationships all over again. That got a laugh, and while it does sound ridiculous, there is a serious point here. And as a Catholic I can’t exactly throw stones at the Anglicans while this debate rages in my own Church. The theological case for same sex relationships being an acceptable Christian way of living was first made in English by Derek Bailey in his1948 volume Homosexuality and the Western Christian Tradition. John J McNeill’s great 1977 book for Catholics, John Boswell’s first book (1982) and then two books by C of E Bishops (1982 and 1989) continued this and since then we have had a host of theological, biblical and other studies which convince me that being Christian and LGBT is possible. Yet many cling to a view that scripture condemns same-sex love. Several papers – psychological and theological since 1982 – have argued eloquently that the use of biblical authority texts to proclaim homosexuality is wrong all rely on supporting an emotional, visceral reaction to this rather than reason. Scripture is used as a weapon to protect entrenched views, and people read the Bible to justify their views. They don’t allow the Bible to “read” them.  That’s wrong in my view, but it’s not homophobia, it is deep seated, emotionally held, and may well be utterly sincere. Sexuality for many of us Christians will continue to be a hot and painful debate issue for decades to come.

And it seems to me something very similar goes on with e cigarettes. There are some who deeply, sincerely have a revulsion to e-cigarettes because they may fear, genuinely, that what has been done on denormalizing tobacco will be undone by e-cigarettes. Or they may look back on their careers and see that this sea change undermines many certainties they have. This is a painful place to be. I was somewhere not far from there on e-cigarettes not that long ago. But while I understand it, it doesn’t mean I am content to leave people there. We must move forward. We cannot use poor science on formaldehyde or particles or distortion of the precautionary principle as a justification for not moving forward. Public Health must be at the sharp end. There is often a delay between evidence and practice at the sharp end, as I remember from the early days of HIV.

Equally there are others for whom the war on tobacco killing people has moved on to be a war on nicotine, or a war on the tobacco manufacturers rather than on tobacco and its consequences.

At the summit I asked one such person why it would not be a good thing if big tobacco stopped making tobacco products tomorrow and made tea-towels instead. The response was “you obviously don’t understand…they are evil.” Really?

We continue to see some authors whose arguments have been roundly refuted repeat, ever more shrilly, their arguments in print on e-cigarettes. There is an ethical duty to speak if we genuinely believe e cigarettes to be harmful and dangerous. But there is an ethical duty too to hear the evidence which refutes us, and keep our position under review. Had we conducted our debate with humility; prudently and carefully on the evidence, would we really have needed the British consensus statement?

And so, we are left with a choice:  refuse to move and see people harmed avoidably.  Or recognise and affirm what can be clearly recognised as beneficial, act when the evidence shows harm, and work as best we can, constantly discerning what the good is, while things are developing. Surely this is where public health skills, brought to serve the good of our citizens, were meant to be?  Serve, discern and protect.