Public Health England insists e-cigarettes are 95% safer than smokingBMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k5429 (Published 28 December 2018) Cite this as: BMJ 2018;363:k5429
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The author reports that e-cigarettes are a safer alternative to wean off conventional smoking. It is reported that vaping devices such as E-cigarettes have helped thousands of people in the UK in quitting smoking. However, there is a substantial number (44%) of smokers that believe vaping is as harmful as smoking or are not aware (22%) that has a much lower risk than conventional smoking. Though the reports of the review from Public Health London (PHE) claim that e-cigarettes are 95% less harmful than tobacco, they still raise various concerns such as attracting teens early into smoking, as well as containing ecologically hazardous carcinogens such as formaldehyde, acetaldehyde and acrolein as classified by International Agency For Cancer Research (IARC)(1).
The author has briefly highlighted the opinion of a chest physician at Imperial College of London that though people switching from smoking to vaping get a substantial health benefit, still the best approach for helping people to quit smoking is a combination of psychological supports and pharmacotherapy such as dual nicotine. Similar conclusions were drawn from research studies conducted in India that suggest the use of a behavioural, counseling and education approach can effectively persuade people to quit smoking (2,3,4).
However, there is a lack of evidence on utilization, safety and efficacy of E-cigarettes in India (5). The risks of introducing vaping devices to the Indian market may include early indulgence of young teenage population in tobacco products, which would be a straight violation of COTPA Act 2003 banning sale of tobacco and related products to individuals under 18 years of age, and cheaper low quality imitation of vaping devices which may burst on repeated use posing physical threat. There is strong opposition from the Indian Government with a ban on the production of Electronic Nicotine Delivery Systems (ENDS) including e-cigarettes, Vape, E-sheesha, E-Hookah, etc., in view of protecting vulnerable populations (children, adolescents, women) from the ill effects of vaping devices (6).
According to the GATS (Global Adult Tobacco Survey, India) 2017 report, 10.7% (99.5 million) of all adults currently smoke tobacco and 21.4% (199.4 million) of all adults currently use smokeless tobacco. In total, 42.4% of men, 14.2% of women and 28.6% (266.8 million) of all adults currently use tobacco (smoked and/or smokeless tobacco), indicating a high burden of tobacco abuse in the country (7). Furthermore, a study by ICMR-NICPR government of India, reported poor compliance of COTPA for control of tobacco in and around schools (8), indicating gaps in implementation of welfare initiatives tobacco control. From the Indian perspective, e-cigarette is nothing more than a nicotine delivery device with an unknown health risk profile and no health benefits, and further needs to be warranted (9).
Thus it can be concluded that in a country with an already high burden of tobacco abuse, the use of E-vaping devices as a healthier alternative can prove to be an additional bane for welfare initiatives in place for smoking cessation. Thus we do not promote the use of e-cigarettes as a healthier choice, we rather suggest prioritizing the use of zero-damage approaches such as a combination of psychological, behavioural, educational and pharmacotherapy via the means of health education and behaviour change communication for cessation of smoking.
2) Murthy P, Saddichha S. Tobacco cessation services in India: recent developments and the need for expansion. Indian J Cancer. 2010 ;47 (1):69-79.
3) Jayakrishnan R et al. Smoking Cessation Intervention in rural Kerala, India: Findings of randomized control trail.Asian Pac J Cancer Prev.2013;14(11):6797-802.
4) Muthusamy SK et al. Community based group Intervention for tobacco cessation in rural Tamil Nadu, India: a cluster randomized trial. Journal of substance Abuse Treatment. 2012; 43(1):50-60.
5) Thampi et al. A Review Study on Vaping and Status of Vaping in India. J Cancer Clin Trails. 2018;3:2.
6) https://google.com/amp/s/m.timesofindia.com/india/centre-asks-states-to-... rettes/amp_articleshow/65585399.cms
8) Sayeed S, Labani S, Asthana S. Peertechz J BioinformBiostat .Compliance of a Government Act on Cigarettes and Other Tobacco Products around Educational Institutions of Noida. 2017; 001-003.
9) Asthana S, Rawat D, Labani S E- cigarettes: The Indian perspective. Current Medicine Research and Practice 2017;7:119-120.
Competing interests: No competing interests
Although we applaud Public Health England’s (PHE) latest campaign tackling the menace of smoking, we were concerned to see the extensive positive coverage of the safety of e-cigarettes compared to conventional cigarettes in the professional press, including your journal.
The claim that vaping is at least 95% safer than smoking has been reiterated as part of their Health Harms campaign. We note that this claim arose from a 2013 consensus meeting of ‘experts’ in which the panel reviewed harms from various nicotine containing products. It was clearly stated in the report of this meeting that “a limitation of this study is the lack of hard evidence for the harms of most products on most of the criteria” and “there was no formal criterion for the recruitment of experts” at this meeting. Additionally, the authors of this document are known to have conflicts of interest, which has been previously documented. For example, an author of this paper reported serving as a consultant to Arbi Group SRL, which is an e-cigarette distributor. There is evidence to show that conflicts of interest such as this produce results that are favourable to the tobacco industry.
It is the view of PHE that e-cigarettes are a useful stop smoking aid. The evidence around people’s use of e-cigarettes in real life is unsurprisingly controversial. A recent review from across the Atlantic summarised the available data regarding e-cigarette use and smoking cessation and concludes that e-cigarettes attract people who are interested in quitting smoking but reduces the likelihood that they will quit successfully. Additionally, people may be using e-cigarettes to maintain nicotine use in environments where this is banned, acting to maintain cigarette use and nicotine dependence. It is well accepted that e-cigarettes contain lower levels of carcinogens than conventional cigarettes, but this of course does not mean that they are harmless. They produce ultrafine particles, which are known to contribute to cardiovascular and lung disease. The known harms of cigarettes certainly seem to be greater than the known harms of e-cigarettes, but the unknown harms ought not to be ignored.
The promotion of e-cigarettes by PHE as a smoking cessation aid is in stark contrast to the recent guidance released by the European Respiratory Society (ERS) in November 2018 and the US Surgeon General in December 2018. The ERS clearly state that there is not enough scientific evidence to support that e-cigarettes are an aid to smoking cessation.
The Surgeon General issues a warning that e-cigarette use is increasingly popular with adolescents and young people in the US. He notes that e-cigarettes have been the most commonly used tobacco product among US youth, and that its use has been increasing since 2011. He notes the harm caused by nicotine to the developing brains of teenagers and that e-cigarette use can increase risk of future addiction to other drugs. PHE have acknowledged a rise in e-cigarette use among young people until 2015, when the trend has flattened. It is important to note that e-cigarettes are appealing to the young, with flavours such as bubblegum and cherry cola, and the recent development of e-cigarette devices that can be easily concealed.
E-cigarettes are potentially available to children in the UK, despite attempts at safeguards against this. In 2016, 40% of sellers tested in England by Trading Standards were caught illegally allowing under 18’s to buy e-cigarette products. It was noted that most of the illegal sales were at markets and car boot sales. Similar results were found in Moray (Scotland) in 2018, where it was found that 66% of retailers tested sold vaping products to young buyers, without proof of age.
An additional consideration when promoting e-cigarettes as a stop smoking aid is the investment by tobacco companies in e-cigarette products available in the UK. Clearly, use of e-cigarettes as a stop smoking aid is a threat to the tobacco industry. Perhaps any means of reducing cigarette smoking should be welcomed, but it seems unlikely that this industry will be supportive of efforts to curb nicotine addiction altogether. New e-cigarette devices are attractive to consumers, sleek in appearance and compatible with people’s high technology lifestyles. Devices that are Bluetooth enabled may soon be entering global markets. According to this product’s developer, this is with the intention of blocking use by young people. The same company has filed patents for such features as multiplayer games controlled by the vape, and collection of users’ data on their vaping preferences. We must note the company state these patents are simply to protect their intellectual property and are not necessarily plans they intend to put into action. But this illustrates the tension between promotion of these devices as stop smoking aids, and of their marketing as attractive consumer products.
Certainly, it seems reasonable to suggest that current smokers should switch to e-cigarettes, due to the known lower exposure to carcinogens, and the established harms of cigarette smoking, but the perception we create among communities that it is extremely safe could potentially increase its uptake, most worryingly amongst the young, when the long-term effects of e-cigarette use are unknown. We should be alert to the limitations of the widely publicised ‘fact’ that vaping is 95% safer than smoking. We should be aware of professional opinions both in Europe and the USA, who have taken a much more cautious approach to e-cigarette promotion. We should be aware of the fact that e-cigarette companies are being bought up by tobacco companies, and the invariable conflict of interest this produces. As PH practitioners we face a dilemma – how do we promote e-cigarette use so that it is only taken up by current smokers, who likely stand to benefit from cigarette cessation, and how we discourage e-cigarette initiation in the young in whom the risks clearly outweigh the benefits. The question facing us here in the UK is - should we adopt a more cautious approach to e-cigarettes like our American cousins and European friends or continue with our current positive promotional approach?
Emma Thompson1, Padmanabhan Badrinath2
This article reflects the personal opinions of its authors and does not in any way represent the views of their employers or any associated institutions.
Competing interests: The authors of this letter currently work in Public Health and are strongly opposed to smoking in any form.
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Competing interests: The authors of this letter currently work in Public Health and are strongly opposed to smoking in any form