Should electronic cigarettes be as freely available as tobacco cigarettes? No
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3840 (Published 14 June 2013) Cite this as: BMJ 2013;346:f3840
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1) The question needs work.
2) Suggested alternative: "Should electronic cigarettes be made more available as tobacco is made less?
2) Answer: Yes
3) Common problem in public health, poor questions lead to poor data
4) Perfect sighted health professional with both personal and public health perspective
Competing interests: No competing interests
Who fears an alternative to tobacco smoking?
The pro and con’s side of the debate about electronic cigarettes could have analyzed the data on other alternative to tobacco smoking.(1,2) These are numerous and have existed for a long time. Eg. Swedish smokeless tobacco (snus), a moist powder tobacco product consumed by placing it under the upper lip for extended periods of time, similar to American dipping tobacco, which is not allowed elsewhere in Europe other than in Sweden. Snus must not be confused with snuff, a product made from pulverised tobacco leaves which is inhaled (snuffed) through the nose.
As the primary harms from smoking tobacco comes from the smoke (carcinogens, co-carcinogens, poisons, carbon monoxide) any alternatives to smoke are simple ways of reducing the deadliest epidemic ever seen. The World Health Organization (WHO) states that tobacco kills nearly 6 million people each year. Tobacco control looks like rearranging the deckchairs on the Titanic as WHO calmly expects an annual death toll of more than eight million by 2030.
Tobacco control’s failure is obvious in developing countries. In most rich counties, tobacco control is at most lazily implemented and the signature of the WHO Framework Convention on Tobacco Control is only a smoke screen as observed for warnings on cigarette packages.(3) Only Canada, the first jurisdiction to require full-colour graphic warnings on cigarette packages, and Australia which has just implemented plain packaging, are exceptions. However, it is Sweden that has the lowest prevalence of smoking among any nation because major shift has occurred from smoking to snus use.
Who can have legitimacy on the issue? Who can we trust: experts, clinicians or politicians? Tobacco control advocates are in a cul-de-sac and even enduringly failling to acknowledge the benefit of risk reduction policies. Thomas Frieden, Centers for Disease Control and Prevention director, underlined that despite 70% of smokers seeing doctors regularly, most try to quit smoking without professional help. Last, governments fear to lose their billions from the 80% charges rate on regular cigarettes and the European Union accepts violation of its founding principle, free trade, to ban snus! Sadly, Britain led the ban.(4)
The Journal must be congratulated for giving Etter the opportunity to pledge for common sense. Readers must be informed that Etter was one of the 10 members of the advisory committee on electronic cigarettes of the French Department of Health (http://www.ofta-asso.fr/docatel/Rapport_e-cigarette_VF_1.pdf). He was the only one to refuse to endorse its conclusions as, coincidentally, he was the only one to have published on the topic in journals indexed by PubMed.
The solution may come from the market. The tobacco companies, clever and fast runners, have entered the e-cigarette market long before policy makers woke up.(1,5)
1 Etter JF. Should electronic cigarettes be as freely available as tobacco? Yes. BMJ. 2013 Jun 14;346:f3845.
2 Chapman S. Should electronic cigarettes be as freely available as tobacco cigarettes? No. BMJ. 2013 Jun 14;346:f3840.
3 Braillon A, Dubois G. Warnings on tobacco packets. Is your MP concerned about public health? BMJ. 2011 Aug 2;343:d4883.
4 Raw M, McNeill A. Britain bans oral snuff. BMJ. 1990;300:65-6.
5 Bains M, Agombar H, Clarke E, Patel R. Time for NHS policy on electronic cigarettes. BMJ. 2012 Oct 17;345:e6587.
Competing interests: No competing interests
The question of the use of electronic cigarettes (e-cigs) and its regulation at the national and international (e.g. panEuropean) level concerns not only the physiological and toxicity aspects, e.g. the association between cancer and smoking, but also some relevant behavioral and psychological aspects, or their psycho-economic equilibrium. Within a community, behaviors spread according to schemes devoted to the search for a psychological balance. This means that a certain behavior will be more prevalent in some communities, the more they are perceived higher in benefits against low perceived costs or risks. The achieved equilibrium is given by the ratio between the number of individuals of a certain community who start a behavior, due to the perception of a psychological benefit, and those who still remain alien to it.
The introduction of tobacco products (and later cigarettes) in Western societies starting from the 16th century had a significant impact. The diffusion curves of cigarettes after the development of the tobacco industry at the end of 19th century show that we have suffered a real smoking epidemic, soothed by cultural traditions before (for example, due to religious or cultural-related limitations) and subsequently by regulations aimed to limit negative effects, once they were known. Being an additive, hence pathological behavior, the psycho-economic equilibrium was reached with great difficulty, as a result of particularly relevant evidence (e.g. the association between smoking prevalence and the epidemiology of lung cancer) and particularly stringent regulations as the smoking ban in public places.
Although many experts felt that a smoking ban would have increased the desire to smoke, the result has been a real success, thanks to the achievement of a new psycho-economic equilibrium, which has prompted many individuals to quit smoking or reduce the number of cigarettes smoked in order to avoid the unpleasant effects of abstinence. In addition, the forced abstinence leads many smokers to seek other ways to manage their negative emotions, which leads in turn to reduce nicotine addiction. Obviously, cultural and social changes might reshape this balance, for example by encouraging women and immigrants smoking, for whom it will be necessary to implement new and more targeted prevention and support programs.
Now the introduction of the electronic cigarette is likely to upset this precarious psycho-economic equilibrium achieved thank to a widespread effort.
It is then necessary not only to understand the toxicity of these new ways of smoking, but also its impact on the mind’s smokers. For example, how the use of e-cigs will affect tobacco smoking? Will e-cigs lead to a new e-smoking epidemic?
The widespread e-cigs communication and advertisements try to reduce the perceived smoking-related risks, by highlighting the benefits of e-smoking. In this way, the free diffusion of e-cigs might scramble the previous equilibrium, without a full and evidence-based awareness of the related consequences on health.
Eventually, a different consideration deserves the use of e-cigs in patients or people at high risk (e.g. due to heart problems), for which quitting traditional tobacco cigarette smoking may lead to a considerable reduction of risk, with clear benefits both for individuals and community, also from and economical point of view. However, this issue strongly suggests the need for a shared and evidence-based regulation able to discern the therapeutic use of e-cigs from the ad libitum use of them, as well as social, behavioral and psychological differences in the adoption of nicotine-based and nicotine-free e-cigs.
Research and regulations are then needed in order to elude a new form of behavioral epidemic, avoiding thus the swapping of an addiction with another one. In particular, we need to know how to guide the contemporary society to a new and efficient psycho-economic equilibrium without wasting all the success achieved during last years in western countries.
Competing interests: No competing interests
I myself began vaping 9 weeks ago after 9 previous unsuccessful quit attempts. The only treatment which worked in getting me off tobacco for any significant period was varenicline which has the unfortunate possible (and alarmingly common) side effect of causing sudden psychiatric disorders including suicidal thoughts and attempted suicide so given the choice of a pill which may make me try to end my life or a simple electronic device which delivers the nicotine I crave with none of the deadly toxins that unfortunately go hand in hand with tobacco smoke, I bought my first ecig.
9 weeks on I am tobacco free, my health has already improved considerably, my lungs function as they should, my children are not exposed to the multitude of toxic fumes that clung to my clothes when I came back in after going outside for a smoke and the online communities and forums that have sprung up around the topic of vaping show that my experience is not unique.
An estimated 1.2million+ people in the UK now use ecigs, presumably for the same reasons I do and if the Government and various Public Health body's main aim is truly that of improving public health and reducing mortality from tobacco related diseases why would they possibly seek to over-regulate the ecig industry and inevitably destroy our best hope yet of seeing the end of tobacco dependency and all the hideous disease and death that it causes.
Would I welcome more study into the long term effects of vaping - Yes
Would I welcome standardised legislation to back up the ECITA standards already adhered to by its members to ensure that the products I buy are safe and effective - Yes
Do I think that Medicinal Licensing is appropriate or necessary for a recreational product that is already self regulated - No
The most likely outcome of Medicinal Licensing is that all but the largest of companies (ie Big Pharma and Big Tobacco) would find it cost prohibitive or indeed impossible to obtain the necessary licensing leaving the market again monopolised by tobacco peddling giants and pharmaceutical companies whose NRT's have dismal long term success rates. The overwhelming majority of consumers would be left to bounce between the two should they wish to quit nicotine completely and medicinal licensing would likely put an end to the option which is now available for those, like me, who want (or need) to use nicotine as a recreational drug for its relaxative qualities without seriously compromising their health.
Formal regulation of the industry is inevitable, but medicinal licensing would prevent further development of new products by making it cost prohibitive and be detrimental to public health as it would inevitably force millions of people to revert to or keep on smoking tobacco and condemn them to suffer the effects of tobacco related ill health which would in turn continue to burden the NHS.
I do not profess to be an expert, a doctor or a scientist but all the information available to me points me to one conclusion, that for a smoker looking for a safe and effective nicotine delivery system, the ecig in my hand is the only option currently available and to over regulate it into an effective ban would be ludicrous and counter productive and their sale to adult smokers should be encouraged, not minimised.
Competing interests: No competing interests
Whatever your views, Simon Chapman's proposal is to move from anecdote to study the outcomes from ecigarette use versus non-use in large populations trying to quit. The more we understand about how to help smokers quit, the better.
Competing interests: No competing interests
Restricting the availability - or taxing and reducing the desirability - of ecigs will result in tens of thousands of UK lung cancer and COPD deaths over the next few decades. It is clear from the hundreds of comments below online newspaper articles that thousands of UK smokers have already given up or drastically reduced their smoking by switching to ecigs. Many, including myself, tried ecigs with no intention of completely quitting smoking, but found they had that effect. The low cost, hundreds of different flavours available and the opportunity to mix ones own liquids to the desired strength are what makes ecigs so attractive as recreational nicotine delivery devices - not medicines. Any interference by the Tobacco Control Industry is unnecessary and will be detrimental, both to ecig users enjoyment and harm reduction. To save further embarrassment, instead of making increasingly absurd and bizarre claims, it should now retire gracefully or stick to kicking the shins of the Tobacco Industry. A problem resistant to hundreds of millions of pounds of taxpayers money, bans and bullying of smokers has been solved by one smoker's moment of inspiration. The Chinese inventor of the ecig should be given the Nobel Prize for medicine. It may only be BP nicotine and disco smoke, but it will change the lives of millions.
Competing interests: No competing interests
Professor Chapman's mask has slipped.
From our exchanges in the past it seems that Prof Chapman is a socialist with a dislike of capitalism. He has said he also dislikes "Big Pharma" as well as "Big Tobacco."
I have my ideology too, I am a libertarian and classical liberal who dislikes the nanny state.
To my mind it is not joined up thinking to call for regulation when in the UK it will cost hundreds of thousands of £pounds, if not millions to get e-cigs approved.
The many small businesses who have exhibited exemplary ethics and commercial tenacity to extend vaping, and will not have a prayer of affording the costs of compliance.
Professor Chapman is playing right into the hands of "Big Tobacco," who have the resources.
In the UK the government spends annually £300 million (about US$450) on tobacco control and it must really irk Professor Chapman that free enterprise has come up with a solution to smoking, and not "Big Government."
If e-cigs are to be marginalised then this will only mean smoking rates will remain constant. This week it was reported that using "Big Pharma" patches and gum has a 94.5% lapse rate after 1 year. Typically 50% of smokers quit with e-cigs.
Also "Big Tobacco" came now claim that have a virtually harmless alternative and it is now the customer's choice which version they buy, and can now have a relatively clean conscience.
Frankly Professor Chapman "Big Tobacco" has won, free enterprise has defeated "Big Government" and their viability and profits will be assured.
Competing interests: I have been expensed and remunerated by Pfizer who make smoking cessation drugs
Re: Should electronic cigarettes be as freely available as tobacco cigarettes? No
I suspect my secretary and I represent a cross-over trial on this one.
I used to smoke about twelve cigarettes a day, my secretary forty.
We both changed to electronic cigarettes. Neither of us has smoked again, though probably imbibing more nicotine than ever before. Extremely significantly, both of us suffered the inconvenience of a flat battery, bought traditional cigarettes and found them unpalatable.
Every year I cycle 56 miles from London to Brighton and run 10 kilometres round London. My times crept up every year, as one might expect with aging, but dropped after the change to electronic cigarettes.
My secretary has reported a huge jump in disposable income, and calculated she has over the course of her lifetime spent a quarter of a million pounds on smoking, out of taxed income.
I don't think anyone could think of a more dangerous way of absorbing nicotine through the lungs than smoking. Vaping more or less has to be safer in anyone's book and on the basis our experience seems to be associated with improved fitness and, crucially, without the usual relapse into smoking or a combination of continued smoking and alternative nicotine provision.
Competing interests: I use electronic cigarettes, but have no shares in the company that makes them.