Intended for healthcare professionals

Rapid response to:

Letters Recommending e-cigarettes

Safety of e-cigarettes still needs to be proved

BMJ 2014; 349 doi: (Published 15 July 2014) Cite this as: BMJ 2014;349:g4597

Rapid Response:

There is so much wrong in such a short communication, that it is hard to know where to start. I would like to draw out four types of error in this letter:

1. Framing errors. The authors appear to misunderstand the concept of harm reduction. It is not necessary for e-cigarettes to be completely 'safe' - they just need to be very much safer than smoking, and not that dangerous in absolute terms for them to have a valuable public health impact if they function as an appealing alternative to smoking. If the BMA officials had studied the experience of snus (smokeless tobacco) in Scandinavia they would understand this concept. In fact, BMA was one of the organisations that wanted this product banned in the rest of Europe, prompting a number experts in the field to write to the Secretary of State for Health to voice their opposition to a ban with evidence [1]. There is a similar framing error in the authors' approach to acute toxicity of nicotine. Not only is their science obsolete and greatly overstates the toxicity [2] but their framing is wrong: we do not generally control toxic substances in the home by banning them or limiting container sizes to below sub-lethal doses: imagine having to buy bleach by the cupful. The approach taken is to classify, package and label the products appropriately - something that is easy to do, and the BMA could constructively support instead of trying to reject the product outright on these spurious ground.

2. Loss aversion and accountability for risks created by restrictive policies. The authors appear oblivious to the risks that their own policy prescriptions might create. Many of the restrictions they favour, and their public relations line, will have the effect of denying these products to smokers or persuading them not to try the products - and this comes with consequences. A very much less risky product (e-cigarettes) than the dominant, highly dangerous, incumbent (cigarettes) comes to market and the medical establishment moves in to oppose it. Surely it is obvious that this risks protecting cigarette sales, increasing smoking, denying smokers options that might work for them, and so contribute to more disease and death. In their focus on small or implausible residual risks arising from e-cigarette use, these authors have not symmetrically accounted for the lost opportunities and risks that their ideas might create. I have set out a more detailed account of this argument, and wish to remind the BMA that it should be accountable for additional preventable smoking that arises from its hostile position [3]. As an example, the authors make a wholly unsubstantiated claim that flavours are added to increase appeal children - there is no evidence at all for that. In fact, flavours are important to adults, and particularly important in supporting a long term move away from smoking. To ban flavours risks compromising the appeal of the product to the intended market (smokers) and so leading to more smoking than there otherwise would be. The authors give no reassurance that they have considered this risk, yet it is more plausibly significant in sign and magnitude than any risks they cite.

3.Use of evidence in policymaking The authors want "long term data affirming lack of harm"... but one wonders what would satisfy the authors, and whether this is simply a tactic to create an insurmountable evidential hurdle? What should be done in the meantime? The British doctors survey that demonstrated the effects of smoking unfolded over 50 years [4]. To make good judgements about risks in public health a physician has to look at all the evidence, weight it by its value, and where there is remaining uncertainty to consider the uncertain risks and potential benefits on an even footing. A good evidential picture can be developed starting from the basic physics and chemistry of the processes involved, the toxicology studies on liquids and vapours, the long established and well studied history of nicotine use where there is no tobacco combustion (i.e. in NRT and snus), the absence of significant reported ill-effects or serious incidents, and expert opinion all suggest that the risks arising from e-cigarettes in general are low and the risks of nicotine itself, while finite, are very low. Cherry picking single studies out of context does not alter that. They are also misrepresent the evidence on whether these products are effective at smoking cessation. There is not just 'one study' showing these products to be effective in smoking cessation - there are several trials and impressive survey data. The survey for ASH for example, suggests some 700,000 current British e-cigarette users are now ex-smokers, whilst use among adolescents and non-smokers is very low [5]. Surely the BMA can extract some evidential value from that? What, on the other hand, are the implications of ignoring it?

Missing humility and empathy. I understand modern medical training includes listening skills and recognises the importance of empathy with patients. I would like to commend this approach to the BMA. It is quite possible that millions of smokers are finding something that works for them and gives them immediate gains in welfare and self-esteem and significant improvement in long term health and mortality prognosis - at least that's what many well-informed say users when they describe their experience. The tone from the BMA and the more reactionary elements of the health establishment is that the views and experience of users simply do not matter or are worthless anecdotes. I do not think this is right - not everything can be understood from RCTs and and thousands of user testimonies now point to huge welfare gains from this technology. I would advise any physician minded to take a dismissive view of e-cigarettes developments to look at some testimonies and remind themselves what the profession is all about. There are many available on the internet, and they make inspiring reading [6].

These issues have been raised before with the BMA and they have promised to consider them [7], but so far the organisation seems more concerned to defend its earlier positions, even though evidence and experience is increasingly leaving it looking scientifically vacuous, impervious to challenge and criticism and out of touch.

[1] Martin Jarvis, Peter Hajek, John Britton, Gerry Stimson, Riccardo Polosa, Karl Olov Fagerström, Michael Kunze, Karl Erik Lund, Jacques Le Houezec, Tony Axéll, Lars Ramström, Clive Bates. Letter to the Secretary of State for Health, Tobacco Products Directive and snus, 7 October 2013. Available online at:
Why is the EU banning Europe's most effective anti-smoking strategy?

[2] Mayer B. How much nicotine kills a human? Tracing back the generally accepted lethal dose to dubious self-experiments in the nineteenth century. Arch Toxicol 2014;88:5–7. doi:10.1007/s00204-013-1127-0

[3] Bates, C. Turning the tables on public health – let’s talk about the risks *they* create? 3 July 2014

[4] Doll R, Peto R, Boreham J, et al. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ 2004;328:1519. doi:10.1136/bmj.38142.554479.AE

[5] YouGov for Action on Smoking and Health Use of electronic cigarettes in Great Britain April 2014.

[6] See examples and links at: Bates C. Where is the humility? Where is the empathy? 30 December 2013.

[7] Bates C. Letter to Dr Vivienne Nathanson, 25 February 2014, Response from Dr Nathanson, 4 March 2014. Unable to take any more, I write to Dr Nathanson of the BMA. A similar challenge has been made by the campaign group Sense about Science What’s the evidence for banning electronic cigarettes: we asked the BMA why they want them banned in public, 12 December 2013.

Competing interests: No competing interests

16 July 2014
Clive D Bates
Sustainability Consultant
4 Pentney Road, London, SW12 0NX