BMJ Editorial: Electronic cigarettes as a method of tobacco control (Ron Borland)

[Tom09]

R. Borland: Electronic cigarettes as a method of tobacco control, BMJ 2011; 343:d6269 (Published 30. September 2011)

intro:

Allow them, but research and monitoring are needed so that the risks can be regulated

Electronic cigarettes (e-cigarettes), cigarette shaped products that vaporise nicotine in ways that enable it to be inhaled, have become increasingly popular in the past few years. 1 2 3 E-cigarettes are a potentially more attractive substitute for smoking than low toxin smokeless tobacco because the nicotine is delivered by puffing, as when smoking a cigarette. A range of products are now on the market, with new improved ones promised, and—something almost unheard of in tobacco use—self organising groups of users (who call themselves “vapers” because they inhale vapour, not smoke)—who are advocating for these products and sharing their experiences. 1 3 Opposition has come from some health groups, either for pragmatic reasons or because they are opposed to any recreational use of nicotine.
[...]

concluding paragraphs:

[...]
Currently it seems that these products pose no serious immediate risk. On balance, by allowing the products to be sold the UK seems to be taking the approach with the greatest potential public health benefit. The approach also creates real incentives to conduct research and to consider more appropriate regulation. The alternative of waiting for the research may end up essentially as prohibition, if no one is sufficiently motivated to do the work.

However, allowing these products does not mean that health groups should actively promote them. Health professionals should begin with evidence based strategies and promote these first. However, health professionals should be able to suggest to smokers who are unable or unwilling to use or continue to use effective aids to quit, and who are interested in e-cigarettes, that these are a better option that continuing to smoke. And although it is better not to use any form of nicotine long term, if patients must, e-cigarettes are a lower risk option than continuing to smoke.

alternative link here

 

[rothenbj]

Sounds like a practical approach, will anybody listen?

 

[Vocalek]

All I can say is, "Wow!"

 

[rolygate]

A very positive article.

It is interesting to see how medical opinion requires that something that obviously works very well indeed (millions of users worldwide for many years, with use growing tenfold per year in the US) needs testing to see if it works. It seems to be working just fine, though perhaps I misunderstand the definition of the term. Perhaps the sky is not blue unless there are multiple clinical trials that say so.

As usual, restricting the options available seems advisable to Dr Borland - removal of e-liquid from the market, and only pre-filled cartos to be available. As this sort of approach is shown to be attractive to only 8% of long-term users, it means the good doctor would like to see 92% of use abolished.

It's always hard to work out why on earth a consumer tobacco product would need to be medically licensed - as that is what all such commentary is basically about - but I suppose that an electrician sees any issue as being electrically-related, a plumber sees issues of whatever type as being plumbing-related, and doctors see everything as being medical. However, we haven't seen any moves to make coffee percolators, briar pipes or cocktail shakers medically licensed pharmaceutical devices yet - I wonder why not? They are all devices that supply a drug with a significant pharmacological effect, so surely they must be medical devices.

And naturally, the safety of electronic cigarettes is questioned. It is, as ever, a complete waste of time pointing out that:

• E-cigarettes have been used by millions of people, worldwide, for many years, and caused no deaths or even any instance of serious harm.
• In the same timeframe, Chantix has caused hundreds of thousands of heart attacks and thousands of deaths.
• Just in the US, and just in 2010, Chantix is reported to have caused 62,500 heart attacks, since it causes a 'cardiac event' in 1 in 30 patients (some studies say more often).
• In total, Chantix has caused hundreds of thousands of heart attacks, thousands of suicides, tens of thousands of attempted suicides, an uncounted number of psychotic events, and several murders.
• E-cigarettes caused nothing.
• Chantix is demonstrably thousands of times more dangerous than electronic cigarettes. Why isn't something useful done about that, rather than chase around after what appears to be an all but harmless consumer product?

Let us hear what the author would say about the potential for iatrogenic death where a doctor prescribes Chantix as against simply advising the patient to switch to e-cigarettes and/or Snus and joining a support group? I would describe such a doctor as negligent in the extreme - but perhaps I'm biased. To me, exposing a patient to high risk with a best-case chance of success that cannot possibly exceed 10%, as against pointing them toward an ultra-low-risk proven successful consumer product that has an 80% chance of success when used with a support group, is negligence. I can't see how it could be interpreted any other way.

In the end, doctors and health industry workers all want control over something that has absolutely nothing to do with them. It's a power and control thing, expanding the empire, nothing more. Decaff coffee has nothing to do with the medics and neither do tobacco harm reduction products.

 

[Bill Godshall]

Ron Borland has supported tobacco harm reduction products and policies for the past decade, but please note that he lives and works in Australia (where both snus and e-cigarettes are banned).

Although I don't agree with everything his op/ed proposes, the primary goal of his op/ed appears to be encouraging e-cigarette prohibitionists to support legalizing e-cigarettes (where e-cigs are banned) and/or to not ban them (where they are still legal).

 

[rolygate]

It's a positive article, and perhaps I'm just being too negative... Just a bad reaction to the empire-building, probably.

 

[Vocalek]

The more e cigarettes are used. the more smokers will be drawn away from smoking, but with the increased risk of substantial uptake by nicotine abstinent ex smokers and those who have never used nicotine (mainly adolescents).

--Borland

"Increased risk"? "Substantial uptake"?

The Etter & Bullen survey is the largest of its kind, and many help to quantify the above percieved risk level. But I found the report confusing because they used a catch-all term of "former smokers" to describe anyone who used to smoke but did not do so at the time of the survey. This makes it difficult to determine whether any of the "former smokers" had stopped all use of nicotine first and then later on took up use of the e-cigarette.

It would have been more precise if they reserved the term "former smokers" for those survey respondants who stopped smoking before taking up e-cigarette use and to have used a different term -- perhaps "quitters" or "replacers" or some other term to describe those who no longer smoked because of taking up the e-cigarette.

Of the 3659 records, 66 were deleted as double entries, leaving 3593 records. Six (0.17% of 3593) were from people under age 18. Since these records were also discarded, (outside the parameters of the study) there is no data on whether these younger respondants actually used e-cigarettes, and if so whether they were smokers when they did so. But even if all six were e-cigarette users, they still represent a very tiny portion of the user base.

Very few (n=4) never smokers used nicotine-containing e-cigarettes but of these, three said they used them to deal with their craving for tobacco and to avoid relapsing to smoking, indicating they were actually former smokers misclassified as never smokers. Most participants were current users of e-cigarettes, but 15.2% were never users and 1.3% were past users.

Not sure how the following statement is supposed to be interpreted:

Most current smokers reported that the e-cigarette helped them reduce their smoking (92%), and most former smokers (96%) said that it helped them quit smoking.

The first half of the sentence is crystal clear, but the second half could mean that

• 4% of former smokers did not use an e-cigarette at all, or it could mean that
• 4% of former smokers used some method other than an e-cigarette to stop but were currently using an e-cigarette, or it could mean that
• 4% of the former smokers used some method other than an e-cigarette to stop, had tried out an e-cigarette, but were not currently using one.

Which is it?

Few (10%) still experienced the urge to smoke while using the e-cigarette, and most former smokers (79%) feared that they would relapse to smoking if they stopped using it.

It's a fantastic finding that 90% of current users do not experience any urges to smoke.

Turning back now to Borland, another thought comes to mind: If e-cigarettes do not present any great health hazards, why should there be such concern about those who previously became abstinent from nicotine taking up use of an e-cigarette? Isn't it better for these folks, who might still be struggling with long-lasting nicotine abstinence problems (such as attention and/or memory), to turn to a reduced-risk source of nicotine instead of relapsing to smoking?

And if an adolescent decides to experiment with e-cigarettes that contain no nicotine, as long as that's where the experiment stops, what's the harm incurred? And if an adolescent decides to take up nicotine use, is it better for him or her to do so by using most deadly delivery vehicle (smoking) instead of a reduced-risk vehicle?

As long as kids taking up smoking remains a health hazard to be reckoned with, perhaps the tobacco control community should give some thought to providing truthful information about the relative health risks of different products instead of tarring every product with the same brush. As long as we tell kids "all tobacco products are equally hazardous", what is the incentive for them to avoid the one that we know is the deadliest?

If someone were to invent a "sober up" pill that you could take when you walk out of a party or the bar and it would remove all the physical and mental impairments that make driving unsafe, would the alcohol control community want to ban it, because it might encourage kids to drink? If they thought the way the tobacco control community does, they would consider the potential for alcohol use among kids to be a much more important problem than folks of all ages getting smashed up in auto accidents.