E-cigarettes under fire – why?

Although they may look similar to conventional cigarettes, e-cigarettes are not lit, neither do they contain tobacco. They are battery-powered electronic devices, originating initially from China that, when the user sucks on the mouthpiece, produce a microprocessor-controlled puff of vapour containing nicotine and propylene glycol.  As such, they reproduce the ‘hand-to-mouth’ action of smoking cigarettes but do not, of course, expose the user to the harmful effects of inhaling tobacco smoke. The apparently growing world-wide popularity of e-cigarettes has drawn attention from numerous health agencies and advocacy groups. Intuitively, one might have thought in a positive sense –after all these devices are almost certainly a lot less risky than regular cigarettes and probably less risky even than smokeless tobacco products. But the prevailing attitude has so far been quite the reverse – some regulatory authorities, such as those in Australia have already banned, others such as those in Canada are in the process of restricting their sale, and in the US the FDA are reportedly planning a crackdown against them (http://www.mercurynews.com/ci_11873938?IADID=Search-www.mercurynews.com-www.)

 So what exactly is all the fuss about? Surely offering smokers another, much less risky, alternative to cigarettes to choose from isn’t a bad thing, even if only a small minority switch? But no, all kinds of objections have been raised to try and either get the products taken off the market or dissuade smokers from using them. These include: have not been proven safe; have not been proven to be an effective smoking cessation aid; might attract kids; children might be poisoned by eating the nicotine-containing cartridges that the devices use; they allow smokers to get round smoking bans.  Taking these objections in order: few, if any, things are completely safe and tests so far, albeit on  only one e-cigarette brand, have found no cause of serious concern; they are mostly marketed as cigarette alternatives rather than quitting aids (but if they help people to quit, surely that is an added benefit); the upfront cost of the device plus charger is relatively high (typically US$100 and up) so they would seem unlikely to attract kids – having said that, they certainly should not be marketed to them; whilst the cartridges should be kept out of the reach and sight of children, the same could be said of many products found in the house; the same criticism could be levelled at pharmaceutical NRT products in terms of them being marketed to reduce cravings during temporary abstinence from smoking. And I’m not the only one to question the evidence that e-cigarettes are a hazard (see for example http://www.24-7pressrelease.com/press-release/ecigarettes-under-attack-by-fda-and-who-are-they-really-unsafe-91658.php) Is it simply the case that some hard-liners in tobacco control don’t like e-cigarettes because in the hands of the user they look like conventional cigarettes?  But what do others think about these products and how they should be regulated? Has anyone tried them?

Experts in Government, Public Health, Public Policy and Science Outline Blueprint for Reducing Death and Disease from Tobacco in the United States

For any of you who might have missed the important announcement last week about the outcome of a two-year dialogue process, mostly involving US tobacco control and tobacco policy experts, a link to it is provided here http://www.americanlegacy.org/2991.aspx. Noting that the primary goal of tobacco control is to reduce the mortality and morbidity associated with tobacco use, the blueprint that emerged acknowledges that the primary reduction in tobacco-related mortality will come from quitting. Hence many of the policy recommendations (e.g. regulation of all aspects of promotion, advertising and labelling and higher taxes) are consistent with such a conclusion. However, at the same time the blueprint acknowledges that harm reduction principles can also achieve public health gains.  As such, policies are also called for which encourage current tobacco users, that are either unable or unwilling to quit, to reduce their health risks by switching from the most to the least harmful nicotine-containing products according to a continuum of risk. On this continuum, cigarettes are seen as being the most harmful tobacco product, with medicinal nicotine products being less harmful than oral tobacco products. To facilitate product switching will require that consumers receive accurate and evidence-based information on the toxicity and relative risk for disease of different nicotine-containing products. This is not before time – it’s crucial that consumers get this kind of information if they wish to self-regulate the risk of their continued tobacco and/or nicotine use other than choose the best option of quitting entirely.  

In itself, the incorporation of harm reduction principles in this way as an adjunct to traditional tobacco control policies is not a new approach, see for example : Tobacco harm reduction: an alternative cessation strategy for inveterate smokers By Brad Rodu  and William T Godshall Harm Reduction Journal 2006, 3:37 http://www.harmreductionjournal.com/content/3/1/37). But this approach is now given additional weight by the collective standing in the field of the participants in the dialogue process from which the blueprint was derived and it’s another step in the right direction for an arguably much more pragmatic regulatory policy given the stalling quit rates in many countries. Is it therefore too much to hope that those policymakers involved in impending discussions, both on FDA regulation of tobacco, and the crafting and implementation of pertinent aspects of the WHO Framework Convention on Tobacco Control will take note? What do you think?

Update on UK Consultation on Tobacco Control: Real opportunity or false dawn for Tobacco Harm Reduction?

The deadline for submissions to the UK Department of Health consultation on Tobacco Control has now passed. I don’t know how many responses were submitted in total, but those I have spotted from tobacco companies can be accessed as follows: BAT here; Imperial Tobacco here ; Jti  here; PMI  here and those from health charities such as ASH(UK) and Cancer Research UK can be accessed  here and  here respectively. On the same day that the submission deadline closed, the Royal College of Physicians issued a new report “Ending smoking in Britain” which can be accessed here. While there is a lot of reading here (and I’m still ploughing through it all myself) I’d recommend anyone with an interest in harm reduction to look through the relevant sections of these submissions and especially the RCP report. I could be wrong, but there is perhaps more common ground on harm reduction (as least as a concept) than one might otherwise anticipate. What do others think?

A summary of responses will be made available on the Department of Health website at the end of the year so I guess we will have to wait and see what their overall take is on things. I should add that I based my own (minimalist in comparison!) response on five core arguments 1) An abstinence-only approach to tobacco control may have had its day; new thinking is needed,  2)  Formulaic regulatory proposals might be counterproductive: long-term beneficial public health outcomes should be paramount, 3)Harm reduction and product innovation; challenges and opportunities should be evaluated objectively, 4)A new regulatory framework covering all nicotine containing products would empower the consumer, 5) Incentive for business transformation within the tobacco industry; a key stakeholder that can be part of the solution. If anyone would like a copy of my submission, just flag this up in a response to this posting and I’ll work out some way to get it to you. Kindly note though that I don’t claim to have a monopoly on wisdom in this area; that’s another good reason to take a look at the submissions noted above, and the RCP report!

Scaring smokers to health found to be ineffective: time for a new approach to health warnings?

Graphic health warnings on tobacco products are not mandatory under the WHO Framework Convention for Tobacco Control. Yet a growing number of countries plan to introduce such warnings on the premise that by doing so, more smokers will be encouraged to quit than would be the case if existing text warnings were retained. However, according to a recent news article, a Health Canada poll has found that graphic health warnings are increasingly seen by Canadian smokers as being ineffective in this regard. Canada was the first country in the world to introduce graphic warnings back in 2001 and the results of the poll are seen by some as indicating that the existing warnings simply need refreshing. This could be so, but an alternative interpretation is that graphic health warnings fail in their purpose because they provoke outright denial, rather than fear, of the consequences of smoking. Also, from a harm reduction perspective, graphic health warnings do not steer smokers towards forms of tobacco and/or nicotine products such as smokeless tobacco, which are now widely considered to be much safer than cigarettes – it’s very much a ‘quit tobacco or die from a grisly death’ message. An alternative approach could be to use the health warning space on the packs to provide the consumer with less threatening information that might encourage him/her to move down the continuum of risk posed by different product formats. For example, packs of cigarettes could perhaps carry a health warning that simply says “Much safer nicotine-containing tobacco and non-tobacco products are available “. Following the same logic, cans of smokeless tobacco might carry a health warning that says “Safer non-tobacco nicotine-containing products are available” Nicotine replacement products might carry a health warning that says” Whilst this nicotine-containing product is safer than tobacco products, no product that contains nicotine is totally safe” Obviously one would have to do a fair amount of consumer research to get the vectored messaging right –but it’s a thought!   What do you think?    How might consumers react? How might governments react?

UK Consultation on Tobacco Control: Real opportunity or false dawn for Tobacco Harm Reduction?

The UK Department of Health has recently published a consultation on the future of tobacco control. This consultation is seen as the first step in the development of a new UK tobacco control strategy and covers four main areas: Reducing smoking rates and health inequalities caused by smoking, protecting children and young people from smoking, supporting smokers to quit and lastly, helping those who cannot quit. While the first three areas build on orthodox tobacco control initiatives, in public policy terms the last area is potentially groundbreaking. This is because it considers the potential of a harm reduction approach. The consultation document (section 5 part D) points out that harm reduction strategies seek to minimize the adverse health and social consequences of substance use and that to date harm reduction approaches have not received widespread attention for tobacco. As the health impacts of smoking are largely unrelated to nicotine, it may therefore be possible to find new ways to reduce the risk to smokers who are unwilling or unable to break their addiction. For this reason it is argued that future UK government strategy in tobacco control should therefore address the needs of the smoker who cannot quit and give consideration to how the harms caused by smoking can be reduced. The consultation document acknowledges that for critics, the disadvantage of even a harm reduction strategy using only ‘pure’ nicotine products is that it involves an acceptance of addiction. Furthermore there are even greater concerns about a harm reduction approach using non-smoked tobacco products, as it would lead to the implicit abandonment of the goal of a tobacco-free society. The fact that harm reduction is incorporated in a consultation document coming from the country currently rated as having the most effective tobacco control strategies in Europe is a very interesting development. Hopefully it is a sign that the debate on tobacco harm reduction is going from fringe to more mainstream. The question posed in the consultation document is “Do you support a harm reduction approach and if so can you suggest how it should be developed and implemented?” Responses (from any group or member of the public with an interest in tobacco control) can be submitted online to the UK Department of Health by 8th September 2008. A summary of responses will be made available on the Department of Health website at the end of the year. What are your thoughts? Will tobacco products get a look in? Will this have any influence on global tobacco control policy?