Dad was a smoker when I grew up in the 1970s, his parents too. Mum’s side of the family didn’t. Mum told me of her experiences nursing people with respiratory illness, including a younger person who was killed by asthma. Dad’s father smoked the occasional cigar, I used to like the aroma around their house.
You can still buy “cigarette stink loads”. In 1978 I bought some from the local toyshop and fixed up one of Dad’s cigarettes. The prank made its presence known in the lounge but he just threw the cigarette away and started another one. Some scarily severe asthma attacks around 1982 convinced Dad to finally quit. Instead he took up distance running. He went on to a marathon PB of 3:03 at Christchurch in 1988.
As kids we used to go into the woods and make forts and puff on bits of straw and cigarettes we’d buy from the old fella at the corner store. A store-owner who sold tobacco to primary students! He seemed ancient to us, but probably hit his teens in the Depression years. It was a different world. Anyhow, those first smokes made no great impression on me, because I had no idea about inhaling. We did learn to cover our tracks with peppermints.
I first inhaled tobacco smoke in a woolshed in Whiteman’s Valley, Upper Hutt, in 1985. Oh boy! Head spins! It is one of life’s great misfortunes to enjoy a cigarette. Blessed are those who smoke and feel sick. They usually don’t repeat it.
Smoking never really worked for me because I was physically active, running or cycling. I could tell that smoking and sport were incompatible. I might enjoy a cigarette, usually with a drink, in the evening. The next day I would feel even worse. I still carry some nostalgia. Is that a curse? Indonesian clove cigarettes, with the sugar on the filter. The pop and crackle of burning clove oil at night. The stars spinning above me!
I studied medicine and was influenced by a surgeon from Australia who had amputated too many smokers’ limbs. He urged us to become active against tobacco. He said it would be the most effective thing we could do in our career. As a medical student I wrote a submission in support of Helen Clark’s 1990 Smokefree Environments Bill. More comical was to recently find a second submission, the one I didn’t send in, that argued the reverse on some points. I usually tried to understand a topic from different directions.
I spent the 1990s training for a career in medical oncology, with a focus on lung cancer. In 2010 I made a submission to the NZ Maori Affairs Select Committee inquiry into the tobacco industry in Aotearoa and consequences of tobacco use for Māori. It supported taxation, cessation services, protection of tamariki, and tikanga approaches to removing tobacco from Māori environments. In the 2010s I continued tobacco control work with Te Hotu Manawa Māori and the Smokefree Coalition. Since 2014 I have been with End Smoking New Zealand.
At the start of the decade I was optimistic about nicotine replacement (NRT) with patches and gum to help people quit, realising that some would need quite high doses. Alas NRT adds only 6–8% to the chance of a sustained quit at 6 months. Even with intensive behavioural support, the 6 month quit was not more than 23.2% in the 2018 Cochrane Review.
During the last decade I have seen tobacco control split over the issue of electronic cigarettes (e-cigarettes). It has often been said that tobacco is an addictive poison. Nicotine brings the addiction and tar brings the poison. Although not totally true, this statement is true in ways that matter.
My colleague Dr Penny Truman from End Smoking New Zealand is doing valuable work on the euphoriant properties of non-nicotine components of smoke. It does not surprise me that nicotine would not be the only euphoriant in smoke. Humans are likely to find smoke appealing, because it means food and warmth. This is in contrast to most animals, that will run away from smoke. Probable exceptions are rats and domestic animals that seek out humans. Penny suspects the combination of nicotine with other euphoriants gives tobacco smoke a double-whammy for addiction.
The marvel of e-cigarettes has been to separate the addiction from the poison in tobacco smoke. We found the same separation in tobacco control. It turns out tobacco control was an alliance between some who were more opposed to the poison of tobacco, and others who were more opposed to the addiction. This alliance was revealed, and strained or broken, by the arrival of e-cigarettes.
A subset of people, strongly opposed to the addictive potential of nicotine, have been trying very hard to find poison in e-cigarettes. In actual fact there is poison everywhere. It is 500 years since Paracelsus taught “everything is a poison – only the dose matters”. So there is an expanding literature reporting toxins in e-cigarette liquids, and effects of e-cigarette aerosols principally in animals, with a small number of studies in people.
There is still no literature to confirm actual physical harm, at a population level, to users of nicotine-containing e-cigarettes. A paper claiming that “some‐day and every‐day e‐cigarette use are associated with increased risk of having had a myocardial infarction” has been retracted.
Of course there must be controls on the ingredients of e-liquids. You probably wouldn’t want to try bitter almond flavour, for example. The main reason we can be confident that e-cigarettes are much safer than smoked tobacco is temperature. An e-cigarette atomises e-liquids at around 240 Celsius. A combustible cigarette burns tobacco leaf at around 900 Celsius. The higher temperature, and complex biological substrate, greatly increase the toxicity of tobacco smoke.
With more than 10 years but less than a lifetime’s experience, it remains possible that an adverse effect of e-cigarettes on population health will emerge. But if it did, that would be a surprise. Whereas we know for a fact that smoking combustible tobacco is highly harmful to health. Some people, motivated by their opposition to addiction, are trying hard to find physical harm in nicotine-containing e-cigarettes. For some people, e-cigarettes are scarily effective nicotine replacement.
Addiction is a harm. It takes away the person’s freedom to choose, and puts them at the mercy of others. In the case of tobacco, those others were an industry focused on profit, that twisted science to deny the harm of its products. There is still a reckoning to be had with the tobacco industry over its historical actions. It remains to be seen whether the tobacco industry can reinvent itself, now there are finally safer nicotine products available.
I’ve tried a cartridge-based, nicotine salt e-cigarette. It popped and crackled like the clove cigarettes of my youth. That was pleasant enough, but fortunately for me I have not felt the need to go back to it. As a society, we tend to ascribe a power to addictive euphoriants that is near magical. “One puff and you will be hooked”. I have not forgotten my first puff in a woolshed in 1985. But there have been other things in my life that prevented me from returning.
As a society, we should ask what is driving our young people into the arms of tobacco. In 2002 my son chased me around the garden at a lunchtime barbecue, outraged that I was puffing on a cigar. He was right! Even at primary age, many young people are aware that smoking is harmful to health. In 2016 my son as a young adult took up smoking, while working at a restaurant. Fortunately he has since switched to vaping. I can’t deny I would prefer it if he stopped.
It is not always easy to be young, with doubt as to what the future holds for work, housing, and the world at large. Human beings have long turned to chemical relief for stress and anxiety. We should grow a kinder society. Until then, for those who turn to chemicals, they should at least have a safer option.
There is indeed a gateway between vaping and smoking, but the direction of travel is set by policy. Good policy pushes to vaping. Poor policy pushes to smoking. When I say “push”, I don’t mean “shove” or even the trendy “nudge”. I just mean that good policy helps people move in a better direction. There are many other gateways in the continuum from harm to health. Good policy helps people move towards health. To achieve good policy takes courage (to venture where others didn’t), faith (that policy will succeed), and commitment (to accept that good is not perfect, and keep improving).