Promotion of electronic cigarettes: tobacco marketing reinvented?BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f7473 (Published 22 December 2013) Cite this as: BMJ 2013;347:f7473
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The long-term effects of e-cigarettes are relatively unknown. Advertisers are exploiting the absence of legislation regulating e-cigarettes, and their promotion, to promote them as a “healthy” and attractive alternative to smoking, using media in which tobacco advertising is illegal. E-cigarettes are consequently an expanding market, with unknown health implications. This reflects the fact that UK law, as it relates to psychoactive substances (including nicotine) is out of date.
There has been an explosion in the sale and promotion of so-called “legal highs” in the UK in the last 7 years. The number of novel psychoactive substances reported to the UN Office on Drugs and Crime rose from 166 in 2009 to 251 by mid-2012. The UK is Europe’s largest consumer of these drugs (1), which have been tried by approximately 5% of 16-24 year olds in Europe. They are becoming more popular year-on-year (1).
The government’s response to minimising the harm caused by “legal highs” has been to classify these drugs under the Misuse of Drugs Act (2) on a case-by-case basis, in many cases making them illegal (3).
There are several problems with this. Firstly, the producers and sellers of such substances can evade classification by making small changes to the molecular structure of the drug they wish to sell (1). The new drug is not covered by existing legislation, and is legal to sell. The cycle then repeats – this process is probably responsible for the explosion in the number of novel psychoactive compounds detected over the last decade (1).
Not only does this tactic fail to control the sale of psychoactive substances to the general public, it contravenes the principles of harm reduction: if the drug-taking population obeys the letter of the law they are acting as trial subjects for chemicals which may never have been tested in animals or humans. The longer a drug is used by the population, the greater the understanding of its effects and risks: new, legal, street drugs are completely untested on any population, and therefore carry a much higher inherent risk to the user.
Secondly, witless consumers have no idea whether the drug which they have consumed is legal or illegal. Sellers also have no idea of what they’re selling. Adulteration of street drugs has always been an issue, but patients now are unable to even name the supposed “key ingredient” of what they’ve taken.
The government is left attempting to catch up with the relentless innovation and marketing of the “legal highs” and e-cigarettes.
I believe a more pragmatic approach would be to ban the import and commercial sale of any chemicals with psychoactive properties, other than those on an “approved list” (e.g. ethanol, tobacco, solvents). The onus would be on the manufacturer to prove that there was a genuine need for the novel chemical, and that it had a low potential for misuse. This would avoid the novel chemical being sold as "bath salts"(7) or "plant food"(8). Another approach would be to require a licence to sell any chemicals with potentially psychoactive properties (including e-cigarettes) – much as shops need licences to sell tobacco or alcohol.
1. UN World Drug Report http://www.unodc.org/wdr/en/nps.html
2. Misuse of Drugs Act 1971 http://www.legislation.gov.uk/ukpga/1971/38/contents
3. Government Press Release https://www.gov.uk/government/news/mexxy-black-mamba-and-other-legal-hig...
4. European Monitoring Centre for Drugs and Addiction: Cannabinoids http://www.emcdda.europa.eu/publications/drug-profiles/synthetic-cannabi...
5. European Monitoring Centre for Drugs and Addiction: Synthetic Cathinones http://www.emcdda.europa.eu/publications/drug-profiles/synthetic-cathinones
6. Office of National Statistics http://www.ons.gov.uk/ons/rel/ghs/opinions-and-lifestyle-survey/smoking-...
7. Ask Frank (UK government drugs advisory service) http://www.talktofrank.com/drug/legal-highs#aka=bath+salts
8. Ask Frank (UK government drugs advisory service) http://www.talktofrank.com/drug/legal-highs#aka=Plant+food
Competing interests: No competing interests
We read with interest the article ‘Promotion of electronic cigarettes: tobacco marketing reinvented?’ by de Andrade, Hastings and Angus (BMJ 2013;347:f7473) and would like to highlight the problems that the emergence of e-cigarettes may have on the surgical patient.
With increased availability and growing acceptability, the use of e-cigarettes means that surgical patients are using them preoperatively and in the immediate post- operative period. The odourless smoke makes detection on the ward almost impossible, and patients no longer even benefit from the mobilization required in order to reach a designated smoking area.
The effects of Nicotine in surgery are controversial[1,2,3]. There is however evidence that suggests that the intake of nicotine attenuates the inflammatory process of wound healing and increases the risk of ischaemic complications[5,6].
Whilst e-cigarettes benefit from a significant reduction in carcinogenic ingredients, their nicotine content varies markedly across the brands. As E-cigarettes marketing companies push the safety and cessation claims, it is important that we highlight to our patients the detrimental effects nicotine, and the E-cigarette may have on the surgical outcome.
1 Lars Tue Sørensen et al., “Acute Effects of Nicotine and Smoking on Blood Flow, Tissue Oxygen, and Aerobe Metabolism of the Skin and Subcutis.,” The Journal of Surgical Research 152, no. 2 (April 2009): 224–230, doi:10.1016/j.jss.2008.02.066.
2 Brian Rinker, “The Evils of Nicotine: an Evidence-Based Guide to Smoking and Plastic Surgery.,” Annals of Plastic Surgery 70, no. 5 (May 2013): 599– 605, doi:10.1097/SAP.0b013e3182764fcd.
3 John W Martin et al., “The Multiple Faces of Nicotine and Its Implications in Tissue and Wound Repair.,” Experimental Dermatology 18, no. 6 (June 2009): 497–505, doi:10.1111/j.1600-0625.2009.00854.x.
4 Lars Tue Sørensen et al., “Effect of Smoking, Smoking Cessation, and Nicotine Patch on Wound Dimension, Vitamin C, and Systemic Markers of Collagen Metabolism.,” Surgery 148, no. 5 (November 2010): 982–990, doi:10.1016/j.surg.2010.02.005.
5 C R Forrest, C Y Pang, and W K Lindsay, “Dose and Time Effects of Nicotine Treatment on the Capillary Blood Flow and Viability of Random Pattern Skin Flaps in the Rat.,” British Journal of Plastic Surgery 40, no. 3 (May 1987): 295–299.
6 Pedro Bins Ely et al., “Nicotine on Rat TRAM Flap.,” Acta Cirúrgica Brasileira / Sociedade Brasileira Para Desenvolvimento Pesquisa Em Cirurgia 24, no. 3 (May 2009): 216–220.
7 Maciej L Goniewicz et al., “Nicotine Levels in Electronic Cigarettes.,” Nicotine & Tobacco Research : Official Journal of the Society for Research on Nicotine and Tobacco 15, no. 1 (January 2013): 158–166, doi:10.1093/ntr/nts103.
Competing interests: No competing interests
The article ‘Promotion of electronic cigarettes: tobacco marketing reinvented?’ by de Andrade, Hastings and Angus (BMJ 2013;347:f7473) quotes an incorrect claim from an electronic cigarette website, saying that NICE guidance recommends e-cigarettes: “Companies are weaving public health pronouncements into marketing campaigns. An e-cigarette Facebook page stated: “NICE [National Institute for Health and Care Excellence] has become the first public institution to recommend the electronic cigarette for smokers who cannot quit”.
I would like to clarify that this is not correct. NICE guidance on tobacco harm reduction (www.nice.org.uk/PH45) recommends that health professionals should offer only licensed nicotine-containing products to people who smoke, as part of a harm-reduction strategy. Products which are licensed by the MHRA are safe, effective and quality assured, such as nicotine replacement therapy products like patches and gum. Currently there are no electronic cigarette products which have received a license from the MHRA, therefore no electronic cigarettes are currently recommended by NICE.
Competing interests: No competing interests