Time to end e-cigarette naivety
It is with reluctance and a heavy heart that I lift the pen to once more address the vexed issue of electronic cigarettes and public health. The last time I did this was in 2014, when, as President of the Faculty of Public Health, I publicly supported the World Health Organisation policy position to treat the Pandora’s box of a proposed panacea for tobacco addiction with an appropriate level of caution. The immediate outcome was an abusive twitter firestorm from a dedicated band of electronic cigarette enthusiasts that I was foolish enough to respond to. This resulted in my self-referring to the GMC for the possibly unprofessional use of the English language and a great deal of personal stress (the referral went no further).
In the ensuing five years the global growth in the market for these new nicotine delivery systems has been enormous. According to the Business section of the Sunday Times, global annual sales of nicotine devices has reached £15.7 billion, with over 3000 dedicated vaping stores in Britain alone.1 A coalition of proponents of the new product include Public Health England (PHE) and the Royal College of Physicians, who have sought to develop a consensus that nicotine devices, accompanied by seductive premises with barely a nod to smoking cessation, are the best thing since sliced bread. This is despite a growing body of research from the United States that indicates the hazard of e-cigarettes (especially those containing sweet flavourings) for hooking a significant proportion of adolescents into nicotine addiction. The advent of stronger doses through a new generation of devices, in particular that marketed as JuuL, over the past two years has raised the stakes. During the last two months a series of deaths from respiratory conditions, and large numbers of hospital admissions attributed to the use of these products, has brought panic to the companies invested in their sale and distribution.
Despite all this, PHE and its select group of advisers continue to claim that these products are 95% safer than traditional cigarettes.2,3 However, a comprehensive review on the impact of e-cigarettes, recently published in the BMJ by Jeffrey Gotts,4 has concluded that these pharmacologically active devices were marketed without the extensive preclinical toxicology testing or long term safety trials required of conventional therapeutic or medical devices; and that current knowledge of their effectiveness is insufficient to determine whether the respiratory health effects of e-cigarettes are less than those of combustible tobacco products. The 95% figure proposed by PHE advisers has been described by the highly respected commentator Professor Martin McKee, from the London School of Hygiene and Tropical Medicine, as ‘astonishing’ – since the only attempt to quantify the risk used a five year follow up, and the authors conceded that they had almost no evidence to go on.5 Mckee also points out that many of the studies that conclude that there is little risk in nicotine devices are often funded by groups that have potential conflicts of interest. This claim is supported by Gotts, who draws attention to his finding that industry funded research is strongly associated with results that indicate no harm of e-cigarettes compared with studies without a potential conflict of interest.
Sadly, this is not the only issue on which PHE finds itself at variance with the views of senior and respected public health opinion. Other examples include its position on health checks, the public health case against fracking, engagement with the alcohol industry through ‘Drinkaware’ and the confectionary industry with the so-called ‘responsibility deal’. As the organisation responsible for public health in England it should not go unnoticed that, since the inception of PHE in 2013, immunisation and cancer screening coverage have deteriorated and there have been increases in sexual transmitted infection rates, drug related deaths and overall mortality rates. If PHE is to fulfil its initial promise and become the relevant national institution that the public needs then something needs to change urgently. A new board is currently being recruited, let us hope that the opportunity is taken to appoint one that can put this important institution back on track.
What are your thoughts on the public health concerns over vaping? Has enough research been done? Feel free to add your thoughts to the comment section below.
- Luke Johnson. The future of vaping seems uncertain, the future for smokers is a dead end. The Sunday Times, 6 October 2019 (https://www.thetimes.co.uk/article/the-future-of-vaping-seems-uncertain-the-future-for-smokers-is-a-dead-end-fkw5p6s5k; accessed 8 October 2019).
- Public Health England. ‘E-cigarettes around 95% less harmful than tobacco estimates landmark review’. Public Health England, 19 August 2015 (https://www.gov.uk/government/news/e-cigarettes-around-95-less-harmful-than-tobacco-estimates-landmark-review; accessed 8 October 2019).
- Professor John Britton. ‘Switch to vaping’ in ‘Letters to the Editor’, The Times 3 October 2019 (https://www.thetimes.co.uk/article/times-letters-wallace-collection-and-making-art-accessible-0250wpcqc; accessed 8 October 2019).
- Gotts J, Jordt SE, Tarran R. What are the respiratory effects of e-cigarettes?. British Medical Journal 2019;366:15275.
- Martin McKee. ‘Vaping safety fears’ in ‘Letters to the Editor’, The Times 7 October 2019.