Better Health For All

by Martin McKee
Professor of European Public Health
London School of Hygiene and Tropical Medicine

Anyone walking through London’s King’s Cross station this week could be forgiven for thinking they had been transported mysteriously to somewhere else. Not, in this case, on the well trodden (albeit fictional) path by way of platform 9¾ on the Hogwart’s Express but rather to an earlier time, when cigarette advertisements were still legal. All along the stairways are pictures of what seemed to be cigarettes set against a soothing, healthy-looking blue background yet when you got up close you realised that they were actually Nicolites. The mistake is easily made. Indeed, the manufacturers take pride in the fact that their products are “designed to look and feel like real cigarettes”, which they certainly do.

As one branding expert said about an advertisement for E-lites, a competing brand, “everything about the ad and the way it’s targeted and it’s marketed to people does appear to be just like cigarettes”.  With both products, the white barrel containing the battery looks just like the tobacco containing part of a cigarette, complete with a LED at the end that lights up when the user inhales. The nicotine container looks just like a filter tip. The marketing strategy is clearly working. Nicolites’ manufacturers advertise it as “the UK’s favourite electronic cigarette”, a claim seemingly borne out by independent sales data showing that their various brands account for six of the top selling brands of e-cigarettes sold in independent shops.

Yet e-cigarettes didn’t always look like the real thing. The early ones were quite different. Mechanical devices looking like something you might find under the bonnet of a car, with names that reflected their strange design, such as sonic screwdrivers, named after the instruments used by Dr Who. There was no risk that anyone would confuse them with a real cigarette. And just like Dr Who, these strange devices have attracted a remarkably dedicated group of supporters, as I discovered recently when I wrote a BMJ article on e-cigarettes. The article came about following the 2013 WHO European Regional Committee, where ministers from many of the smaller European countries were discussing the advertising blitz they were experiencing from the manufacturers of e-cigarettes (the ones looking like the real thing).

I did some homework and it rapidly became clear that the tactics used to market these so-called cig-a-likes were exactly the same as those used by the tobacco industry. These featured prominently highly sexualised advertisements and references to celebrity users, such as Katy Perry, Leonardo DiCaprio, Kate Moss and Lindsay Lohan. The e-cigarettes often contained flavours known to attract children, whether in cigarettes or alcopops, such as bubble gum. I heard from colleagues in several countries of new outlets springing up outside schools.

In my paper, I recognised that, just like any nicotine delivery device, e-cigarettes could play a role in helping people quit, although as most quitters succeed unaided, it is likely to be quite minimal, and anyway, the latest evidence from a New Zealand randomised controlled trial showed that they were no more effective than patches. But that wasn’t the point. The real issue was the way that these products, “designed to look and feel like real cigarettes” offered a means to get round advertising bans and to counteract one of the most effective measures against smoking, the campaign to denormalise it.

This had been so successful that those celebrities who did smoke would conceal it. Yet, as was already becoming clear, some were willing to be seen vaping, the term used to describe using e-cigarettes. And of course, e-cigarettes, if allowed to be used in public spaces, would undermine the remarkable success of smoking bans that have been policed by popular consent as bar staff would have to constantly check whether what someone was using was the real thing or an electronic copy.

I didn’t call for them to be banned. I simply called for them to be regulated just like other nicotine delivery devices and for advertising to be banned. In the light of what I have subsequently learned, I would add three more requirements. First, no company (including subsidiaries) should be able to manufacture both e-cigarettes and real ones. Second, they should not be designed to look like the real thing. And third, they should not be allowed to be used anywhere smoking is banned.

The response to my paper was remarkable. Within an hour of it being posted on the BMJ website I was the subject of dozens of messages on twitter. Most portrayed me as an idiot, but a significant minority believed I was evil (or both, calling me a “vile cretin”). I had absolutely no idea of the ability of those promoting e-cigarettes to mobilise so quickly and effectively!

So what had I done to upset them? Well, the main criticism was that the e-cigarettes I, and my colleagues at the WHO meeting were seeing advertised everywhere were not real e-cigarettes. Those attacking me sent dozens of pictures of the metallic contraptions they used, none of which looked anything like a cigarette. Indeed, the abiding impression is of what one might see if anyone ever created a museum of spark plugs. They also sent testimonies of how e-cigarettes had helped them cut down or quit smoking. Leaving aside the abusive tone of most of the messages, I was perfectly willing to accept what they said. They obviously did use these devices and I am sure that some of them found that they helped them to quit, even though I was equally sure that there were many more people who had quit without them.

When faced with such sustained criticism, it is important to reflect on whether you might be wrong. I put the term “e-cigarettes” into Google Images and, lo and behold, the vast majority of pictures were just like the ones I had seen advertised. There were a few of the mechanical devices, but only a very few. Then, some of my Twitter followers helpfully send me pictures of e-cigarettes being advertised in other countries. They also looked like the real thing. In some of the pictures, however, you did have to look hard as they were placed just beside the candy shelves, exactly where you would expect a kid to look.

The tide of abuse continued for several days. These things happen when you stand up for public health. But then something strange happened. Someone created a web page with a picture of me, subtly changed with reds, yellows and pseudo Cyrillic font, to look like a Soviet leader. They warned that I was “eliciting howls of rage from the vaping community, McKee is attempting to show vapers in the poorest possible light. Thuggish neanderthals who lack the wit, intelligence and willpower to abandon their filthy addiction to nicotine. Foul-mouthed fake smokers who will launch personal attacks upon a widely respected public health professional. It’s crude, but it can also be effective.” It was as if I had laid a trap into which they had fallen. If only I was so clever!

They accused me of a fundamental disdain for harm reduction, a strange argument as I chair the Global Health Advisory Committee of the Open Societies Foundations, the leading global funder of harm reduction in the drugs field. The attacks subsided for a while, but soon recovered, following the publication of a letter in the Daily Telegraph signed by the leading UK organisations working for tobacco control, including FPH, ASH, the RCP, Cancer Research UK and many others, as well as a large number of individuals, me included. The letter showed a clear consensus in favour of regulating e-cigarettes as a medicine and banning their advertising, the position I had advocated in the BMJ and which is supported by the UK government.

So what do I conclude from this experience? There is clearly a dedicated, highly vocal community using devices that look nothing like cigarettes. Many of them are, doubtless, deeply committed to harm reduction, but I argue that they miss the much bigger picture. However, given what we know about the tobacco industry, now that it has jumped on the e-cigarette bandwagon, it would be foolish to ignore the possibility that some of those responding with such speed and intensity to any challenge to e-cigarettes represent industry-manufactured Astroturf rather than spontaneously emerging grassroots.

Second, there are many small-scale manufacturers of these devices, some of whom almost certainly came into the business because they want to help people quit, although others probably saw the opportunity to turn a quick profit. But, with all due respect to these groups (even if it is not reciprocated), they are essentially irrelevant in the greater scheme of things. Big Tobacco once saw e-cigarettes as a trivial issue, given the work they had done to perfect the real thing as a product designed to attract kids. However, in the past year that has changed completely. It has spotted the new opportunities to circumvent advertising bans, via brand stretching and ambiguous imagery, and to renormalize actions that look for all the world like smoking.

Altria, the owner of Philip Morris USA, has just launched its first e-cigarette, MarkTen, using a subsidiary company. R.J. Reynolds has launched its new e-cigarette, Vuse. Lorillard acquired Blu Ecigs, one of the market leaders in the US and is expanding outlets rapidly. The small companies that initiated the manufacture of e-cigarettes will be swallowed up, as in every other field of commerce, and e-cigarettes will simply be a marketing extension of the real thing.

Unfortunately, some of the most vocal supporters of e-cigarettes seem oblivious to this development, with Clive Bates contending that “The normal controls on truth and fairness in advertising, supplemented by restrictions of the type applied to alcohol, should be sufficient to balance public health opportunities and fears that something might go wrong.”  Those working in the alcohol field might consider this rather at odds with their experience.

Simon Chapman, perhaps the leading tobacco control advocate worldwide, has argued that “The indecent rush to facilitate the growth of ecigarettes may prove to be one of this century’s most myopic and catastrophic public health blunders.” He continues “I so hope I am wrong.” Sadly, I fear that he won’t be.

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