Electronic cigarettes: Ongoing human experiment without ethics approval
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