Episode 4: Professor Andrew Bush

Oli Lewington

One of the things I've always loved about the Royal Brompton and Harefield Hospitals is the pioneering and world class research programs here. They develop new treatments, they improve care for patients, and they help inform decision making and policy across the NHS. My guest for this episode is a great example of all of that. Having authored nearly 700 papers over his career, including a huge amount that have helped better understand cystic fibrosis, the reason for my double lung transplant. But not only that, he's also recently been involved in campaigns around the world aimed at stopping the advertising and promotion of e cigarettes to children. Just a couple of weeks before this recording in February 2024, the UK government announced that they would be banning the sale and supply of disposable vapes in an attempt to prevent the worrying increase in use by young people. Although no date has yet been set for the ban.

This episode allowed me to understand the reasons behind the ban, and the risks posed by vaping by speaking to one of the key people behind swaying the government to take this drastic intervention, and to see if he thinks it goes far enough.

STING

Oli Lewington

Professor Andy Bush is a consultant pediatric chest physician, who's been part of the Royal Brompton and Harefield Hospitals for more than 30 years. He's also currently a professor of pediatrics and pediatric respiology at Imperial College London. Andy has held visiting professorships at Melbourne Children's Hospital, Wake Forest School of Medicine in North Carolina, and the Children's Hospital of Philadelphia. He also currently holds a prestigious post as a National Institute For Health Research senior investigator. Professor Bush has regularly spoken out about the unknown dangers of vaping, and the concerning level of marketing aimed towards children. In this interview, I spoke to him about why he feels campaigning against vaping is so important, the changes in medicine over the course of his career, and what possessed his son to take on this year's London marathon. But I began by asking him about a looming 6 foot tall polar bear that sits or rather stands in his office at the Royal Brompton Hospital.

Andy, thank you so much for talking to us this morning.

Professor Andrew Bush

Pleasure. Thank you for having me, as they say in the best pediatric circles.

Oli Lewington

So before we get into the meat of this discussion, I I'm not with you this morning, but I have seen your office. And I wanted to ask you the the story behind the the giant polar bear that you've got there.

Professor Andrew Bush

Well, the giant polar bear used to appear at Christmas on the children's ward, and he had his own Facebook page. And he used to have a new outfit made for him every night by the night staff. But unfortunately, even though I can find no record anywhere of a large white polar bear being an infection risk, he was banned from the ward as an infection risk, and I had to take him in to avoid him being exported permanently from the hospital.

Oli Lewington

And is that the general story behind the the vast number of of different small, cuddly things that you've got in your office as well?

Professor Andrew Bush

They've gradually accumulated over the years, sort of presence people have given me. There's bears that were gonna be thrown out, which is you simply can't throw out a bear. It's just not possible. I think I'll probably have to retire when the bears leave me no more room in the office. But at the moment, we're knocking along together quite okay.

Oli Lewington

So a polar bear becoming an infection risk is obviously one significant change but you've had a a long and illustrious career, if I can if I can put it that way. You've dedicated your whole career to to children and young people. What are the biggest changes that you've seen in the way that medicine is practiced?

Professor Andrew Bush

Alright. Rewinding back to when I was a little toddler and I had an eye operation, there was no question of your mom staying with you in the hospital. The moms were all thrown out at 4 o'clock in the afternoon, and the procedure that was done as 2 night admission, which is now a day case, parents were chucked out. It was all very much more unfriendly than it is now. And I suppose the biggest change has been more and more focus on the child in the family and making the hospital as child friendly as possible. On the technical side I suppose imaging particularly brain imaging has changed dramatically, the use of flexible endoscopes telescopes into almost every orifice you can imagine to get samples and the absolute staggering basic science advances that are now delivering us hugely significant treatments in the field of cystic fibrosis, in the field of spinal muscular atrophy. So many treatments resulting from a real fundamental understanding of the basic biology of the disease and real personalised medicine.

Oli Lewington

From a completely selfish point of view, I love the amount of work that you've put into cystic fibrosis over the years. CF is the reason that I had a double lung transplant in 2007, and so I know that the work that you've been part of has contributed massively to the changes in CF treatment and the changes in understanding of CF, as you say, the basic science developments all the way through to more personalised medicines. You're named as an author on, I think, it's more than 700 different research papers, which is a frankly ridiculous amount of research papers to have been part of. Are there any particular pieces of research that you've done that stand out in your mind or things that you're particularly proud of being part of?

Professor Andrew Bush

Well, all of these things are a team effort. Doctors flying solo just achieved nothing. You need to be part of a team. I've been incredibly fortunate in the number of brilliant collaborators. I've had brilliant, brilliant team members both in the clinic and basic science. I suppose one of some of the things that I think we've made a difference is in the understanding of really severe asthma in children and airway phenotyping and trying to understand matching the right medicine to the right patient. And cystic fibrosis, of course, you're well aware the the new molecules, which are absolutely spectacular.

I've been a spectator marveling at the science, from the from from the side. And we're also beginning now to get into the an understanding of of wheeze in quite small children and the early origins of disease. So one of the things that we've got to learn is that at most adult diseases have their roots in childhood or or in the pregnancy or even before conception. And if we're going to make a difference to adult health, we've really got to start early. Too late when they're adults, it's too late.

Oli Lewington

And talking about getting involved in things early, one of the major focuses of your time right now is is around vaping and particularly children and vaping, which is is incredibly concerning quite apart from the fact that, you know, they're supposed to be for over eighteens. The fact the fact that children are vaping is incredibly concerning. But what is it that you're particularly trying to communicate and and to achieve with your work in in that area at the minute?

Professor Andrew Bush

So the first thing to say is that nicotine is a drug of addiction. Quite young children, who are addicted seriously to nicotine as a result of vaping. The next question, of course, is what other chemicals are in vapes? You may remember that Dame Sally Davis was our chief medical officer, and she's a woman with a brain the size of a panTechnican. She's a really, really intelligent human being. And she said she did not know what was in these vapes. And if somebody of her caliber doesn't know, nobody else does either.

And if you look at the ingredients list, they're very bland sort of flavorings and stuff like that without particularizing. The lungs, as you well know, are very delicate organs, and they're not designed to have a lot of hot chemicals inhaled into them. And that seriously concerns me. The lungs are delicate structures. So there was an outbreak of an interstitial lung disease and inflammatory lung disease in Korea with a 60% mortality. And, eventually, it was tracked down a cause with disinfectant fumes that the disinfectant had been put into a humidifier. Disinfectant had been inhaled from the room, and this has caused a serious disease.

We can't afford to be careless about what we inhale into our lungs.

Oli Lewington

And there was a ban that was recently introduced by the UK government. What does the ban cover?

Professor Andrew Bush

What they are banning is disposable vapes, and there are good reasons for doing that. The first is these things are pocket money prices. They're easy of access for children, for young people. They're cheap.

They look attractive. And that's what a lot of them are using. There's also environmental issues from this. I'm not a particular expert in environmental science, but I can find no realistically useful model whereby chucking away a lot of disposable vapes is anything other than a bad idea.

Oli Lewington

You've been part of, a similar campaign to introduce a ban in Australia, which I think came into effect last summer, the summer of 2023. What other countries are are leading the way in approaching vaping and banning vaping?

Professor Andrew Bush

So Australia, as you've highlighted, is is one of the prime movers. We are lagging well behind. We're the odd man out in the world, in our perception of of ecigarettes. Different countries have have different have different restrictions. Some have some have ban trying to ban imports, so that's easier said than done. But I think we need to stress that we are well off the pace. We're the we're the odd man out, and either it means we're the smartest people in the on the planet, or we've got it seriously wrong.

And I'm afraid I think it's the latter.

Oli Lewington

There are a lot of people who just don't believe that vaping can possibly be as bad as smoking cigarettes, given everything that we know about the dangers of tobacco and the amount of research that's gone into lung disease related to to cigarettes. And on the face of it, they do seem relatively harmful. You know? They I mean, they certainly smell better than cigarettes do. And what what do you think it is about vapes that causes people to not consider them the same level of danger?

Professor Andrew Bush

So, of course, you're right. Tobacco is very harmful. Nobody in their right mind would advocate that people should smoke. It's very harmful. The list of diseases caused by smoking is enormous and we're still making new discoveries. And we're also making discoveries that if you smoke, this is affecting your will affect your children and your grandchildren. It really is a problem.

So what about ecigarettes? Well, the first thing to say is that the acute reaction to vaping, which is rare, can be very serious indeed. So there have been children, young people using legal vapes who have got who have gone on ventilators in the intensive care units have gone on life support machines, heart bypass machines ECMO is the technical name as a result of acute exposure. Now this is rare, but it happens. And the acute toxicity of ecigarettes is much greater than the acute toxicity of tobacco. If you dabble with cigarettes behind the bike shed, obviously, that's a dangerous thing to do. But the acute response is likely that you vomit and make a fool of yourself.

But with e cigarettes, you can actually get seriously ill. We then now come to the chronic long term effects, and we simply do not know because they haven't been around long enough. I'd like to point out that the late, very great sir Richard Doll took 30 years to convince us all that cigarettes cause lung cancer, And we're still making discoveries about the bad effects of cigarettes. I don't think we can afford to wait 30 years to reassure ourselves. The precautionary principle is to treat these things as harmful and to look at the chemicals, the hot chemicals that are being inhaled and think this is really seriously not a good idea at all.

Oli Lewington

Granted this was quite a long time ago, but Public Health England, as they were then, once said that vapes were, I think, 95% better than cigarettes. Do you think that statistic was just made up, or was it simply misinformed?

Professor Andrew Bush

When it was produced, The Lancet, one of the leading medical journals on the planet, wrote an editorial which completely trashed it. You can't do a 30 year study in less than 30 years. And I would also point out that most of the vapes are made by the tobacco industry. And at the time when smoking was being investigated, they did their best to sow confusion and and hide data. And their record of trustworthiness and openness is not one that is very commendable. These are the people making vapes.

Oli Lewington

How do you combat that from a campaigning perspective when there are things that that tend to linger in people's minds, when there are old statistics that don't really stand up to any sort of scrutiny. How do you combat that and work to change people's minds? Whether that's trying to discourage people from actually picking up a vape in the first place or campaigning against them to the lawmakers and governments and things like that?

Professor Andrew Bush

So this is all very difficult. As you know, there's a lot of stuff circulating on social media and lapped up uncritically. Stuff that is frankly away with the fairies and you cannot get rid of it. It's there and it's very difficult, particularly also, there is no question that the industry is using social media to try to advertise to the young and to try to peddle their stuff. So Juul's, who are a manufacturer of e cigarettes, were settled a lawsuit brought in the United States against them for advertising to children.

They settled that for half a $1,000,000,000. That is a serious sum of money, and the marketing is at young people. Well, we can do something about that. We should be legislating. We should be treating these things exactly as tobacco. No advertising, no displays, no use of them in public in public places, no sponsorship of sports events. I'm old enough to remember things like the Benson and Hedges Cup and the John Player League in cricket.

We're coming back to those days, and it's vapes. I mean, it's terrible. How can that be allowed? And we also ought to be banning all these sexy flavors. You pointed out, I think they smell very nice. They do. This is a deliberate ploy.

So we need to ban flavorings. And the WHO has just produced a position paper on this and now advocating really stringent measures and saying if, you know, if they're being used for smoking cessation, we've got to be done in such a way as they're not seen as cool and sexy and appealing to ensnare young people who are as yet not using them.

Oli Lewington

So they're being used for smoking cessation? So people are being encouraged to pick up a vape to stop them smoking cigarettes?

Professor Andrew Bush

So there are smoking cessation clinics, and I don't work in them. I'm not an expert. I don't see adults. There are numbers of strategies that that these that smoking cessation doctors use and these include things like nicotine patches, nicotine gum. There are medications that are used and some of them think that e cigarettes are a way of stepping down from tobacco. Now if a reputable smoking cessation doctor wants to prescribe them, and I use the words prescribe advisedly, wants to prescribe them to somebody to help them get off tobacco, then fine. I'm not gonna speak against that.

What I would say is that the idea of just transitioning from tobacco to vapes is only half the part the issue. You need to then transition from vapes to nothing nothing at all. And in terms of transition, I mean, one of the things there's been some epic scandals, as you probably know, that their vapes have advertised how much nicotine is in the liquid. But actually, what's inside in the liquid is much greater. And I can't help thinking that if you're giving higher concentrations of nicotine than cigarettes, this isn't gonna be a strategy to to break nicotine addiction.

Oli Lewington

Because these things are being marketed in ways that children find attractive, is there a risk that children who would never consider picking up cigarettes or tobacco use will start vaping instead?

Professor Andrew Bush

I think there's a big risk. I think most people now know that tobacco is harmful, and it's not a particularly sexy thing anymore. It used to be sold as something very cool, again bit like e cigarettes now, women used to market tobacco cigarettes. I think most for most people, the days of tobacco cigarettes are numbered. And fewer and fewer people are taking them up, And more and more people are trying to give them up. Both of which is excellent. But that means, of course, the industry has a problem.

Where are they going to get their money from now? And they need to create a new market of addicts, and they need to create young addicts. No point in getting somebody as old as me addicted because I'll be gone in a few years time and that there's their source of income gone. But if you've got a young addict who's got decades of life ahead of them, then you're gonna make serious amounts of money.

Oli Lewington

You mentioned there the difference between the acute response to vaping as opposed to tobacco and how ecigarettes differ to your immediate reaction to cigarettes. And that's one of the things that's most concerning, isn't it? Coupled with the fact that a lot of the cases that have been documented are very young children presenting at a and e departments.

Professor Andrew Bush

Yes. Indeed. It is very concerning. The reports of children as young as 9 and 10 being brought to a and e departments, with vaping related illnesses. It's very, very concerning how many children under 18, the so called legal age, who are accessing these things. What we're doing is just not working. We are not keeping these things out of the hands of children, and there are consequences.

Oli Lewington

And there there have been some extreme reactions to vaping that we wouldn't and haven't seen elsewhere. What sort of things have happened to young people who have tried ecigarettes?

Professor Andrew Bush

So there are case reports of bleeding into the lungs, of severe allergic reactions in the lungs, of fat accumulation so called Lipoid Pneumonia in the lungs. Probably about 15 or 20 different respiratory illnesses have been described as an acute consequence of E Cigarettes. And there's just recently been a paper published documenting those who are in homes where somebody vapes. You've heard, of course, of secondhand smoking, passive smoke exposure. Passive vape exposure also increases symptoms of breathlessness and bronchitis and cough. I'm not an expert in other in other systems, systems, whether whether there are other side effects that have been reported. But the respiratory ones, I'm certainly concerned about.

Oli Lewington

The point that you make about the content of the vapes is also significant, isn't it? I I know that trading standards have raised concerns about different levels of nicotine, about the levels of ingredients that are contained within the fluid. How is it possible that these things are allowed to be on sale when we don't know what's in them?

Professor Andrew Bush

You tell me, and then we'll both know. They are pedaled. Oh, it's all sort of bland flavorings and stuff like that. You know, you eat flavorings every day of your life. So so, of course, you can inhale them. Well, that's that's not just not sensible. And there's I don't know if you're aware there's an asthma form of asthma and occupational asthma by the effects bakers who make bread, who if they inhale flour get an asthma attack, but they're able to eat bread perfectly safely. You know, it's not rocket science breathing something into your lungs and swallowing them into your stomach are 2 rather different things.

I don't know how these things are allowed. I think the complacency with which we've allowed them to be put on the market when we simply don't know. And if you look at some of the studies that have been done when you heat these chemicals, the number of compounds that are inhaled, we simply do not have inhalational safety data on these compounds. And that worries me a lot.

Oli Lewington

Vapes have been one of these things that have emerged relatively slowly since they were first introduced as as an alternative to smoking. And as you say, a lot of that started with the tobacco companies wanting to offer people a a quote unquote healthier alternative as people were getting more concerned about smoking cigarettes and other forms of tobacco. Was there a particular tipping point for you where something that you were seeing or something that you were experiencing took you from a sort of generalized interest and concern to a point of actually taking action?

Professor Andrew Bush

So I can't think of a one specific Rubicon moment that really changed me. I my levels of anxiety were getting greater and greater as I saw the prevalence figures for experimenting with vapes going up and up, particularly in North America because generally where North America starts we follow. I was also indirectly involved in the care of a young person who ended up in intensive care after vaping. And that certainly was a wake up call. But the general tide, there isn't a sort of big inflection point, though. I suspect that a number took it up in in COVID when there were cheap vapes. People were in a bad place with during lockdown and things like that.

I suspect that did not help. But it's the general tide of the prevalence going up and up and up, combined with the extraordinary complacency of our political masters in allowing this to happen. You know, I'm all for a tobacco free world, but what we need to be is a nicotine free world. And, you know, the breathtaking hypocrisy of the tobacco industry say, oh, yeah, of course we want a tobacco free world. Yeah. Only if we can make our money peddling nicotine in another form.

Oli Lewington

Do you think there's enough funding going into exploring the the long term impacts of vaping at the minute?

Professor Andrew Bush

Probably not. Let me put it this way. I think the onus is on the industry to show that vapes are safe. Look. If I had a new medicine that I wanted you to take, you would want me to show you that it was safe, wouldn't you? They need to show that this is safe. They need to fund the studies if they think they're so damn safe, which they won't.

But it will take time. And I look at the papers and see the multiplicity of chemicals that are generated. I also think of new inhaled medical therapies and the stringent testing that they have to undergo before they're allowed onto the market. And there's an enormous disconnect. It's apparently okay just to sell because they're not medicines, it's okay to sell them willy nilly. And that is really worrying. You know, to me to me, until you know that inhaling something is safe, you're better off not doing it.

Oli Lewington

It's a strange disconnect, isn't it? That people at inhaling medications are desperate to know that what they're inhaling, or even what they're just taking in pill form or whatever it might be, they want to know that they're safe, but people are quite happy to try something recreationally without really knowing anything about it. And I wonder if people just assume that because it's available on the market, it must be safe.

Professor Andrew Bush

I think that must be the assumption or the fact that maybe also when when you're a teenager, you know you're gonna live forever. You know nothing bad is gonna happen to you.

And 30 is extreme old age. So you're really not interested. You're interested in the here and now. If you talk to young people, why do they vape? It's easy accessibility of the vapes and social pressures. And I remember one young man telling me vividly there's no no good talking about saying, oh, well, your chest will be bad when you're 35 if you vape. You know, why why worry when you're about what's happened when you're a very old person of 35?

And we need to do more. And I think we need to get get involved those people who've been hooked on vapes and got off them. Because the one thing that's very clear is that a teenager is not going to listen to an old person like me. They're certainly not going to be interested at all. We've got to get peer delivered educational material out there and start young.

Oli Lewington

Given your background, given the fact that you've dedicated your career to to children, do you feel a duty to talk about the things that you're talking about and to get involved in these kind of campaigns. Is it a duty, or is there, another reason that you you get involved?

Professor Andrew Bush

It's a duty of care to preserve the health of children, not just those who are actually sitting opposite me in the hospital, but out in the community because we'd all agree that prevention is much better than finding a cure. And if we can prevent ill health, if we can prevent the long term consequences of exposure to nicotine, that has to be a good thing to do. That has to be the role of the pediatrician. Just as colleagues are and I are campaigning on things like climate change, on socioeconomic status, on child poverty and obesity, these are pressing issues for children's health, and therefore, anybody who remotely cares about children's health should be getting themselves involved, at least in my view.

Oli Lewington

When we talk about the difference between cigarettes and ecigarettes, what are the overlaps in the toxicity between the 2? Nicotine is obviously a common ingredient. Are there other things that they have in common and things that maybe they don't?

Professor Andrew Bush

Yes. So we know, as you say, that nicotine is in common. And there are numbers of scientific studies that have looked at the inflammatory and immune pathways that are altered by tobacco, by e cigarettes, and by both. And there are certainly common toxicities between the 2. And indeed tobacco impurities have been found in e cigarette liquids however what is very clear is that e cigarettes are not just a sort of watered down version of tobacco. They have their own bad effects which are not shared with tobacco. And, of course, in fairness, the same can be said about tobacco.

Everybody should disabuse themselves of a notion that this is some sort of milk and water version of tobacco it's much safer because it's dilute blah blah blah it's not it's got its own particular toxicities and we're only scratching the surface. Remember we there are literally thousands of different vape liquids and each of these contains goodness knows what or how many ingredients. We're only beginning to scratch the surface. And indeed, we probably never will do more than that, because to study all these liquids is gonna be a task, a labor of Hercules. And as as more and more come on the market, there'll be more and more gaps in the evidence.

Oli Lewington

Should we be redirecting funds from researching the impact of cigarettes and tobacco into researching the impacts of ecigarettes and vaping?

Professor Andrew Bush

So, clearly, there is a lot of interest and right interest in what ecigarettes and tobacco can do. And, you know, we are still discovering new bad things about tobacco. I think what we really need is a big financial and energetic focus on public health. We know enough about tobacco to know that smoking is a bad idea. In my view, we know enough about e cigarettes without any more data that they're a thoroughly bad idea. Yes. We should be finding data because there are still people using them, and we wanna help them. They're victims.

But we really know enough to say we do not want e cigarettes as part of the life of this country. We just do not need them.

Oli Lewington

When it comes to funding research, your son is actually trying to raise some money for the Cystic Fibrosis Trust and their their research and support programs. At the moment, he's taking on the London Marathon inspired by your career. That must feel pretty good?

Professor Andrew Bush

It does. I'm very proud of him and of all my children. If you read his blog, he, pulls my leg fairly mercilessly, and that and that's fine. He's raising money for the Cystic Fibrosis Trust. It's a it's an organization that's dear to my heart that's funded clinical activities and our research activities at the Brompton Hospital for many, many years. And also, of course, the clinical and research activities across the country. So it's a really great cause.

Matt Bush running the London Marathon, please sponsor him. It's a great cause. And as he said, he's doing it as he says it'll save him buying me a 70th birthday present. So there you go.

Oli Lewington

One of the things that I'm trying to achieve with this podcast is exploring a little bit about what I see as the unique community within the Brompton and Harefield Hospitals. You've obviously been part of the hospitals for a long time. And I wonder what you think is behind that very singular sense of community within hospitals.

Professor Andrew Bush

I was certainly, I've been involved a long time, more than 33 years. And yes it is a community. I mean I know my colleagues well, I know who to go to if I've got a problem. I know where I can get advice. I know who's a good opinion. And like we discussed a bit earlier, it's about teamwork, isn't it? It's about teams these days.

No one person, whoever they are, can know all they need to give the best care to a patient. So, yeah, the Brompton and Harefield is a community and a community that I value very much.

Oli Lewington

Professor Andy Bush, thank you so much for talking to us today. I really appreciate your time. And I think it's it's been a really interesting insight into not only the work that you do, but the work that needs to be done going forward.

Professor Andrew Bush

Thanks very much indeed.

Oli Lewington

Chatting to Andy was fascinating. Obviously, I'm predisposed to liking him, purely because of the amount of time he's invested in cystic fibrosis research. But his focus on vaping and the amount of work he's doing to public size its effects is enormous. It's so scary that we seem to be making the same mistakes all over again when it comes to companies being able to advertise and promote products that are proven to be harmful in the short term, and we have no idea what their long term impacts are. We obviously need more research, but we also need a proper public pushback against them. While I'm here, I also want to wish Matt well in the marathon, and I know that the money he's raising will go to really important work by a charity that I'm very close to. Thank you for listening to More Than A Hospital, and we'll talk to you next time.