E-cigarettes: friend or foe?

Anticigarette leagueI’ve spent the past week immersed in the literature about e-cigarettes. The debate is amazingly polarised, from those who fear e-cigarettes will perpetuate the tobacco epidemic to those who think they could save millions of lives.

There is no doubt that smoking tobacco is hugely harmful and e-cigarettes are considerably less toxic to human health. E-cigarettes also seem to be more attractive to smokers than conventional smoking cessation aids such as nicotine replacement therapy patches and gum.

Yet the industry is at present unregulated, meaning a wide variation and uncertainty about manufacturing standards, the amount and strength of nicotine in each e-cigarette capsule and the flavourings used to make them more palatable. Different regulatory authorities are taking different approaches to the problem, meaning that what’s regulated as a tobacco product in one country may be considered a medical device in another, or a food product in a third.

In addition, there’s fear that e-cigarettes will ‘re-normalise’ smoking. I’m sure I wasn’t alone to double-take the first time I saw an e-cigarette advert on the side of a London bus. It brought back memories of the days when cigarettes were freely advertised and the upper desks of buses were a fog of tobacco smoke. In the interim, smoking has become anti-social. Will e-cigarettes make smoking seem glamorous again?

But the key unanswered question is whether they actually help people stop smoking tobacco. Perhaps surprisingly, there has only been one randomised controlled trial in smokers wishing to stop smoking, which compared e-cigarettes both with and without nicotine to NRT patches. The study was inconclusive, with disappointing tobacco quit rates for all three treatment groups.

E-cigarettes are perceived to be a less harmful alternative to smoking, which can help wean people off tobacco. Yet the research base to recommend them simply isn’t there. People can’t make informed decisions about how to stop smoking until big, good-quality studies are complete.

Image of vintage anti-tobacco campaign materials: from Wellcome Images with thanks.

Why smoking is (still) the worst thing you can do for your health

When I saw the headlines claiming that eating a high protein diet was ‘as bad for you as smoking’, I snorted and got on with my breakfast. I know that a headline like that is likely to be based on spin, over-inflation of some observational study results and a slow news day. There were more important things happening in the world.

Then I saw my Twitter and Facebook feeds. People were genuinely concerned, confused and upset by the news stories. People who were trying hard to reach a healthy weight, follow a decent diet and be as healthy as possible. People who have no reason to doubt what they’re told by researchers or health journalists.

I won’t do an analysis here, because NHS Choices’ Behind the Headlines has got it covered in their piece here. It’s a prime example of asking about just one factor (in this case the proportion of protein in people’s diet) and doing a crude analysis of the mortality statistics. It tells you little about the other habits of the people in the study. Did their protein come from lean chicken, or from fried burgers? Did they have a healthy green salad alongside, or a pile of chips? Did they pick up their meal at the drive-through takeaway, or cook it themselves after cycling home from the gym? No idea.

Worse, the results were ‘cherry-picked’. So overall, for all age groups, eating moderate or high amounts of protein was not linked to higher death rates. For people over 65, eating a high protein diet was linked to a lower likelihood of dying. For only one group – those aged 50 to 65, it was linked to a higher likelihood of dying. When the results are all over the place like this, I’m immediately suspicious.

Worst of all, the comparison with smoking – which was made in the press release – was not based on anything in the study. It was a crude comparison between the link to increased death rates in their study, and in other studies looking at smoking. It’s not a valid comparison, because the people in the studies are not the same. And, as NHS Choices point out, ‘We need to eat protein. We do not need to smoke’.

Many, many studies have repeatedly found that smoking causes disease and early death. This one study about high protein diets does not trump those years of patient research. If you do just one thing for your health on No Smoking Day, make the decision to stop smoking. Want to know what will help you stop? See BMJ Best Health’s Stop Smoking topic for more details.

The case of the missing evidence

Elementary, my dear Watson. It didn’t need the return of Sherlock Holmes to work out that you can’t take a fully-informed decision without knowing all the evidence.

I wrote a year ago about the scandalous situation that exists in the field of medicines research, where pharmaceutical companies can quietly hide away inconvenient data from clinical trials that don’t have the outcomes they had hoped. The All Trials campaign, backed by BMJ, brought the issue into the open. We’ve heard a lot from the industry since about its good intentions to behave better in future, to register all clinical trials as they are started, and to disclose all information to the regulators. The industry seems to hope this will make the problem go away.

So doff the deerstalker to the sleuths of the UK’s Public Accounts Committee, which today published its own report on the subject. Their outrage is patent, if phrased in Parliamentary language. ‘We were surprised and concerned to discover that information is routinely withheld from doctors and researchers,’ they say. And, they note, despite the promises of the pharmaceutical companies, ‘None of the latest proposals from regulators or industry adequately addresses the issue of access to the results of trials from previous years on the medicines in use today.’

They have a rather important example. Back in 2009, the world faced an outbreak of pandemic flu. The outbreak was real and cost lives. Fortunately, its effects in the UK were less lethal than originally anticipated. This means many now dismiss it as hype. But as the PAC observe, pandemic flu remains a very real threat. It’s higher on the list of civil emergencies than coastal flooding  or terrorist attack. Being well-prepared is vital.

If we had an outbreak of lethal flu, we’d want access to the drugs most likely to save lives, and very quickly. The drugs would need to slow the transmission from person to person, and prevent life-threatening complications. So the UK has spent millions of pounds on stockpiling the drugs that seemed to have the best evidence in support of them. Tamiflu, an anti-viral drug in tablet form, is one of them.

The UK’s drug regulator told the investigation that they were confident they’d seen all the data relating to the effectiveness of Tamiflu. Yet when the internationally-renowned research experts Cochrane Collaboration looked at the data, they came to a different conclusion. ‘We found a high risk of publication and reporting biases,’ they wrote in their review of the effectiveness of the drug. ‘We are unable to draw conclusions about its effects on transmission or complications… Full clinical study reports are unavailable to us.’ In other words, they couldn’t say whether Tamiflu would do what we will most need it to do in the event of a pandemic, because not all the evidence was made available.

The drug’s manufacturer has now agreed to supply the full study reports, and Cochrane will review the evidence and its conclusion. The PAC noted that it was ‘extremely concerning’ that this situation had taken five years to resolve.

The committee’s report makes some very simple recommendations. All study results should be published, including previous trials of drugs in use today. All trials should be registered, retrospectively if necessary to capture trials started before registration came into force. The drug regulators should demand all the information to which they are entitled (and share it with each other), and the evidence regarding the UK’s stockpile of Tamiflu should be reviewed, once Cochrane has finished its work.

Elementary, perhaps. Let’s hope Mycroft is listening.

Seeing the world differently: science books

Winton PrizeWell, that’s my Christmas list sorted. Some of the most exciting writing being published at the moment will never be listed for the Man Booker, and can’t be found under the label ‘fiction’. If the Royal Society Winton Prize for Science Books 2013 is anything to go by, it’s to be found in science.

The six books on the shortlist span the air and the sea, ranged from barely-discoverable particles to barely-imagined beasts, took us from cells to Cezanne’s apples, and called into question whether anyone who was at the awards ceremony will be able to agree with anyone else about what happened.

The challenge and achievement of good science writing is to make the complex comprehensible, to convey the excitement of discovery without short-changing the hard slog that precedes it, to make connections so that people who never made it past physics GCSE can see the world in a different light.

The shortlisted authors each had a go at explaining how they did it. They agreed that analogies were crucial, but dangerous. Analogies, one author pointed out, ‘permeate professional science’. Cells refer to monk’s spartan dwellings; particles and waves take their cue from the sea shore. What is this thing like, how can I describe it so that someone else can get their head around it?

There was agreement that literary techniques and storytelling were crucial in getting a point across. Humour, too, was seen as enormously helpful, especially in keeping the attention of undergraduate science students in lectures. ‘Humour works because you get people to see things in an unexpected way,’ commented one author. Scientific research also can involve turning around the way we understand the world.

The evening’s host, comedian Dara O’Briain, would have had no argument with that. He’s brought a whole new audience to science through his witty and entertaining TV programmes, and was an engaging and thoughful interviewer of the shortlisted authors.

So which to recommend? I’ve yet to read any of them, but the three I’m most tempted by are Charles
Fernyhaugh’s Pieces of Light, about how the memory works (clue: it’s not like a video recorder); Tim Birkhead’s Bird Sense, in which research students get up close and personal with gannets, and Ocean of Life, Callum Robert’s call to arms for us to embrace the wonder of the oceans and protect their life, before it’s too late. The judges, who presumably have read all the books, voted for Sean Carroll’s The Particle at the End of the Universe, about the search for the Higgs Bosun. And if I was to wake up on Christmas morning with Enrico Coen’s Cells to Civilisations, or Caspar Henderson’s The Book of Barely Imagined Beings, I’d be pretty happy too.

What I learned at E-Health Insider Live

What do you get when you invite thousands of healthcare tech developers, systems vendors, information officers and interested clinicians to a vast conference hall on the outskirts of Birmingham? The E-Health Insider Live conference is now a big event, with presentations from the great and the good, the commercial and the public sector, and everything in between.

I spent a day at the event, gleaning news and ideas to take back to the office. It’s hard not to be overwhelmed by just how much information is available at such events. Not being a techie myself, I found some presentations impenetrable with jargon. But there are always nuggets of gold. Here are some I picked up:

  • Regulation of medical apps is on the cards from NHS England. It’s likely to follow the same route as FDA regulation, but will not be at the same level as regulation of medical devices. There are already 150 patient-facing apps in the NHS England app library, which is likely to become part of NHS Choices mk 2.
  • Also on apps, specialist app store Our Mobile Health talked about their work to curate a library of apps for customers such as hospitals, where the hospital wishes to ensure their clinicians are only using reliable products. The company tests and reviews the apps to find a collection they can recommend.
  • NHS England’s National Director for Patients and Information, Tim Kelsey, spoke about his vision for all NHS datasets to be open and transparent so that everyone, from charities to commercial companies, can make use of them. He referenced Patients Like Me as a group he admires. He said NHS Choices will be rebuilt on an open API so that the structure will be there for people to build communities and collaborative social movements on that platform.
  • Kingsley Manning, chair of the Health and Social Care Information Centre, said his priorities for the next 18 months were data security and quality, better national technology services and information to support better care – by which he meant a library of indicators of good quality care, and providing datasets to allow people to assess them.
  • Dave Coplin, Microsoft’s Chief Envisioning Officer, lived up to his amusing job title by challenging us all about why ‘work isn’t working’ and how we need to move away from the busywork of playing email ping-pong, to make technology work for us. I’m not sure whether he was in the room to hear a plea from a speaker on the Handi Apps stream that the NHS should ‘free itself from Windows’ and reliance on any one software provider…

One final thought regarding conferences. Why are they the way they are? We shut ourselves inside an aircraft hanger for a day, with no natural light, no fresh air, and expect people to sit and listen to others talk for 7 hours. Is it any wonder heads start to nod by the end of the day? How about a re-think of the big conference, making better use of technology? Interactivity, virtual attendance and some fresh thinking might mean we can all take away more than a handful of key points from a day trip to Birmingham.


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