Hospitals are wrong to ban e-cigarette useBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5063 (Published 30 September 2015) Cite this as: BMJ 2015;351:h5063
All rapid responses
I thank the various respondents to my article on e-cigarettes for their contributions to the debate. Unfortunately, their arguments all contain errors. Douglas Mackenzie failed to detect my sarcasm in the article: obviously nicotine patches and gum can be used in Scottish hospitals. My point was simply that it was ridiculous to claim that smoking cessation aids have no place in Scottish hospitals. More importantly, he does not make it clear why it would be a problem that schoolchildren in the USA do not regard e-cigarettes as a great risk. All the evidence shows that they are not a great risk, so all this shows is that the children are well-informed.
Prof Schuurmans also underestimates the potential advantages of e-cigarettes. As seen in the recent Public Health England report, there is substantial evidence that e-cigarettes are effective in reducing harm and increasing cessation rates (two separate things, a point that Prof Schuurmans does not acknowledge). It is rather ironic that he states that “If electronic cigarettes were the solution to tobacco addiction they would have reduced smoking prevalence dramatically by now in countries where they are freely available” while also arguing against their use. Perhaps they are actually the solution, but the entrenched attitudes of e-cigarette opponents such as himself prevent them from being used to good effect. Furthermore, “first, do no harm” is not a precept of bioethics, but of medicine, and quoting it in order to attack a new technology that could ultimately reduce harm is misleading.
Alain Braillon suggests (perhaps not entirely seriously) a collaboration between the NHS and the tobacco industry to provide e-cigarettes to patients. For obvious reasons, any e-cigarettes provided by health services should not generate profit for those who created the deadly addiction in the first place. Rainer Kaelin goes further and appears to suggest that my arguments have been paid for by the tobacco industry. This would be offensive if it weren’t so laughable. If he were up-to-date with the literature, he would be aware that I am very skeptical of tobacco industry involvement in general, and e-cigarette research in particular (see my recent article in Addiction ). It is also entirely wrong to say that my argument is that there should be no regulation: at no point in the article did I say anything of the kind. It is disappointing that so many doctors and public health experts have such a hatred of the tobacco industry that it blinds them to the extent that they cannot objectively assess the potential benefits of e-cigarettes. Their collective attitude appears to be that there is no smoke without fire, and that e-cigarettes must be opposed at all costs, even if this approach costs smokers their lives.
1. McNeill A et al. Ann McNeill and colleagues reply to Martin McKee and Simon Capewell. BMJ 2015;351:h5010
2. Shaw DM. Etter JF. Elger BE. Should academic journals publish e-cigarette research linked to tobacco companies? Addiction, online early. DOI: 10.1111/add.13067
Competing interests: No competing interests
The author's argument is fundamentally the same as the point made in 2013 by J.-Fr. Etter in his Editorial: there should be no regulation of E-cigarettes, because by this new technology of administering Nicotine, the tobacco epidemic will cease by itself, since nicotine dependent persons will switch to the cheaper and safer product and quit tobacco consumption. Thereby, by the dynamics of the free market the tobacco epidemic will decrease and finally die by itself.
There are fundamental flaws in this proposed "logical argument":
1. E-Cigarettes are not as good as conventional cigarettes for administration of Nicotine; that's the reason, why they are not useful for smoking cessation.
2. It is naive to believe that the tobacco industry, having heavily invested in the E-Cigarette Market, will do so, in order to help their dependent customers to stop to buy and to use the "real thing" (the tobacco Cigarette). It is rather plausible that they push this product for promotional reasons (what nicer thing than a movie star with a E-cigarette banalizing smoking and vaping) and for banalizing Nicotine consumption.
3. Banalizing Nicotine and Nicotine consumption will finally result in more Nicotine addicts....and therefore in more people trying the best way to get the drug into their brain, by the tobacco cigarette. Since Big Tobacco will certainly manage the drug-nicotine tobacco-"disinformation on health-beliefs"-system in order that their original product (i.e.the tobacco Cigarette) will dominate the Nicotine/tobacco market. Money will always be stronger than anything else, and certainly stronger than the logic of an ethics expert.. -- The harm reduction song has already been sung to us, precisely by Big Tobacco, when they sold to the public , and they succeded to make us beliefe in, "milder Cigarettes", with huge economic success, but no proven harm reduction whatsoever. They are trying the same old game again.... This time they seem to have instrumentalized professionals from the Ethics field to preach their gospel....and to make them forget that the fundamental ethical rule for doctors and hospitals is to do NO harm; and in this case this means not to endorse the rather unsafe, unregulated, unstandardized device called E-cigarette under the unproven token, that it would be "less harmful".
Competing interests: No competing interests
Should hospital create joint-ventures to promote e-cigarette? The road to hell is paved with good intentions!
Shaw considered that banning e-cigarettes in hospitals means missing a great public health opportunity and supported giving free e-cigarettes to patients.(1)
To obtain free e-cigarettes, considering the shortage in funding, hospitals could create a joint venture with the tobacco industry which have purchased e-cigarettes’ companies and registered for patents (http://www.theguardian.com/business/2014/jun/26/e-cigarettes-market-vapo...). Only dinosaurs with paranoid cranks can fear such a win-win policy.(2)
As a clinician and an advocate of Evidence-Based-Medicine, I prefer to prescribe psychotherapy plus a combination of various forms of Nicotine Replacement Therapy or plus varenicline. Indeed, empiricism may cause deadly harm, even for preventive medicine (eg. the prone position to prevent cot death).
Could Shaw provide us with his personal view on heat-not-burn products which could be even more attractive than e-cigarettes? Indeed, RJ Reynolds and Philip Morris have just marketed Revo and HeatSticks, respectively, scaling up their enduring efforts to protect their addicted consumers health, which began with the marketing of low-tar/light cigarettes, although Einstein warned: "Insanity: doing the same thing over and over again and expecting different results."(3)
1 Shaw D. Hospitals are wrong to ban e-cigarette use. BMJ 2015;351:h5063.
2 Edwards R, Bhopal R. Beyond conflict of interest. Biomedical journals need a concerted response against influence of tobacco industry. BMJ. 1999 Feb 13;318:465-6.
3 Braillon A. Electronic cigarettes: from history to evidence-based medicine. Am J Prev Med 2014;47:e13.
Competing interests: No competing interests
David Shaw criticises the ban on electronic cigarettes in Scottish hospitals and suggests that electronic cigarettes should be freely available for patients in this setting (1). This suggestion may be intuitively plausible and appealing to the masses, but it is not supported by data. Based on published evidence electronic cigarettes are not more effective in supporting smoking cessation when compared to available smoking cessation medication and there is no convincing evidence that consumption of electronic cigarettes instead of tobacco cigarettes leads to effective harm reduction. Electronic cigarettes long-term safety is not known. Short-term safety and analysis of vapour composition suggests presence of less toxic and less cancerogenous components than in tobacco smoke. Variability of the product and lack of standardisation makes general conclusions on product characteristics and usefulness to replace or reduce cigarette consumption practically impossible.
Electronic cigarettes are mostly used with nicotine containing liquids and thus its use potentially promotes nicotine dependence.
Shaw works in Switzerland where the sale of nicotine containing electronic cigarettes and liquids is prohibited, but importation of nicotine containing electronic cigarettes products for private consumption is allowed within certain limits (2). Swiss pulmonologists do not recommend electronic cigarettes for smoking cessation and have voiced a number of concerns in this context (3). Some countries have banned electronic cigarettes entirely. In countries where electronic cigarettes with nicotine are available they have not convincingly reduced smoking prevalence. One reason may be the fact that many electronic cigarettes users cannot entirely stop smoking tobacco products so they use both depending on the situation, what is known as dual consumption.
Primum non nocere (first, do no harm) is one of the principal precepts of bioethics that all healthcare students are taught and is a fundamental principle throughout the world. This principle should be respected in the context of electronic cigarettes, a non-standardised, non-medical product with no proven benefit to resolve the tobacco epidemic or lead to effective harm reduction. If electronic cigarettes were the solution to tobacco addiction they would have reduced smoking prevalence dramatically by now in countries where they are freely available. This has not happened.
Banning this product from hospitals in Scotland may after all be the right way to go and certainly the human research ethics board will approve of it. They may decide that allowing electronic cigarettes to be used without defined specifications or sufficient safety track record is a human experiment without ethics approval and written informed consent from participants is lacking. - It is time to get the producers of these products to take on responsibility and accountability for this ongoing experiment. The alternative to smoking is smoking cessation with repeated professional counseling using approved medication aiming for nicotine abstinence and the hospital setting is ideal to initiate this process.
(1) Shaw D. Hospitals are wrong to ban e-cigarette use. BMJ 2015;351:h5063
(2) Schuurmans MM. Electronic Cigarettes: Lifestyle Gadget or Smoking Cessation Aid?. Praxis (Bern 1994). 2015 Jul 1;104(14):733-7.
(3) Schuurmans MM, Barben J: Stellungname zu E-Zigaretten. Schweizerische Aerztezeitung 2014; 95: 16–17.
Macé M. Schuurmans, MD
Division of Pulmonology
University Hospital Zurich
Competing interests: No interests to declare. I am a member of the Working Group for Tobacco Prevention and Smoking Cessation of the Swiss Society of Pulmonology, and a member of the Federal Expert Commission for Tobacco Prevention
Shaw's article on smoke free hospital grounds in Scotland makes a number of valid points, including the additional harms of cigarette smoke in comparison with e-cigarettes. However some of Shaw's lines of attack are simply smoke and mirrors.
Shaw unfairly sweeps up established nicotine replacement therapies (e.g. gum, patches) into the same category as e-cigarettes, using a rushed comment in a press statement to support his claim. Gum and patches do not model smoking behaviour, and Shaw must know that they are widely prescribed and used in hospitals.
Shaw talks about public health gains from e-cigarettes. The US school survey referenced by Shaw found rising use of e-cigarettes and a great majority of children do not consider e-cigarette use as a "great risk" (1). Child vapers surveyed typically use e-cigarettes as a primary source of nicotine rather than a substitute for cigarettes. These are worrying findings. Shaw's claims for a public health dividend from e-cigarettes are not convincingly supported by the references he cites.
It is still early days for smoke free hospital grounds. Shaw is unduly pessimistic to write them off. Parallel work on enforcement, support and education can always be improved, and needs to be given a chance. There are too many potential harms, and existing therapeutic alternatives, to support wider use of e-cigarettes at the current time. Otherwise work towards a tobacco free future risks going up in smoke for another generation.
1) Johnston LD, O’Malley PM, Miech RA, Bachman JG, Schulenberg JE. Monitoring the future: national results on adolescent drug use—2014 overview. 2015. www.monitoringthefuture.org/pubs/monographs/mtf-overview2014.pdf
Competing interests: No competing interests