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E-cig debate misses the point

April 7th 2014

Last week’s announcement that the Welsh Government was considering extending the ban on smoking in public places to e-cigarettes has caused a furore. It’s provoked inevitable claims about Wales’s ‘nanny state’ and its failure to attend to alleged systemic failures in the NHS, as well as some scepticism about the benefits of a ban amongst public health professionals. But it misses the real point – achieving an effective reduction in tobacco smoking.

There’s no doubt that e-cigarettes are booming in popularity – ASH estimates that there are now 1.3 million users in the UK and that 35% of smokers have tried them. E-cigs are also big business – walk down any high street and there are dozens of retailers promoting exotically-named products. They even sponsor Merthyr Tydfil Football Club.

The answer to a smoker’s prayer?

E-cigarettes provide an alternative source of nicotine to tobacco, as a vapour when a smoker sucks on the e-cigarette.  As a means of ingesting nicotine, they are essentially the same as various other nicotine-replacement products such as patches and gum (although not regulated).

The evidence on the effect of e-cigarettes on health is relatively limited. ASH’s review concludes that ‘there is little real-world evidence of harm from e-cigarettes to date’, and they certainly seem to be less harmful than smoking tobacco.  The sellers of e-cigarettes have latched on to this quickly and are pushing the so-called ‘health benefits’ relative to tobacco hard. For example CloudCigs claims:

Our E-Cigs are far healthier than tobacco, they don’t contain the tar or toxic chemicals that tobacco cigarettes contain …

The evidence on the effects of e-cigarette vapour on other people is even thinner – to the extent that, at present, it seems to be virtually zero. 

Do E-cigs help smokers to quit?

The jury is out on the role of E-cigs in quitting. A substantial proportion of people using e-cigarettes use them to help them to quit, with many claiming that they are successful. Basically smokers like e-cigarettes – not only are they relatively cheap and easily accessible, but they also involve what ASH calls ‘the hand to mouth behavioural component’ (i.e. they’re more like a fag than a patch or gum). However, some research suggests that they don’t deliver a sufficiently reliable dose of nicotine to be effective quit aids, although some public health professionals quoted in a UK Parliament briefing suggest that their potential as a quit aid should be explored further.

It’s interesting that what little evidence there is suggests that almost all those who do use e-cigarettes are current or former smokers who are using them as an alternative source of nicotine, rather than being non-smokers attracted to a highly addictive drug by vanilla and strawberry flavours and gaudy marketing.

Should they be banned?

So this is when it gets contentious.  So far, e-cigs don’t look as if they harm their users (and even if they do it is less than tobacco), don’t harm other people, don’t lead to increased take-up of nicotine products and might even help with quitting.  Yet despite this, the Public Health White Paper released last week proposed banning using e-cigarettes in public places on the grounds that they ‘normalise’ smoking, encourage addiction to nicotine and make enforcement of the ban on tobacco smoking difficult.  The evidence for these claims is scanty and for each claim there is contrary evidence. 

Missing the point

There is absolutely no doubt that Wales has a massive health problem caused by smoking.  Each year smoking causes the deaths of more than 5,000 people, and causes long-term ill-health amongst thousands more.  The Welsh Government has adopted a laudable but extremely ambitious target of reducing the proportion of people who smoke to 16% by 2020. 

What does the Public Health White Paper have to say about achieving the target? Nothing new. There is plenty on more bans and greater regulation of the sale of tobacco products – but nothing to achieve the dramatic increase required in the number of quitters. The Welsh Government’s target requires more than 20,000 smokers a year to quit successfully, but at the moment Stop Smoking Wales helps just 1,000 people a year to quit for at least 52 weeks.  At current rates of quitting, the target is on course to be missed by a mile. 

All the evidence suggests that a ban on using e-cigarettes in public places will – at the very most – have only a marginal effect on the biggest public health challenge Wales faces.  Yet e-cigarettes are the one thing that smokers say works! Rather than more bans, we need radical action to get thousands to quit – what if e-cigarettes were part of the solution not the problem?

Victoria Winckler is Director of the Bevan Foundation. 

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5 Responses to “E-cig debate misses the point”

  1. I think this is a good article.

    Perhaps the only point I’d make is that not everyone who quits smoking tobacco would do so with “official” help from Stop Smoking Wales. Most would do so by themselves.

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  2. jonny says:

    Well, yes, but, there is little evidence (though won’t be able to hold that line much longer – maybe the BF could commission some).

    What about re-normalisation?

    What are the health effects of unregulated inhaled substances – does choco-mocha-fudge-o’teen cause less damage than sandalwood? In every batch?

    What if my kids now see me puffing away on this brightly lit, brightly coloured, cool little gadget I’m always playing with and using when I’m happy and to cope with my stress…? What is that going to do to incidence?

    Who do you think is behind this new innovation in nicotine addiction?

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  3. Tim Watkins says:

    You might also be missing the point on this one. There have been two distinct aims of smoking reduction initiatives. First, and most obviously, they have tried to get current smokers to quit. However, in medical circles it is widely accepted that once smokers have reached 50, much of the damage has been done (although the risk of heart disease lowers after quitting, the risk for most other diseases remains). In cold economic terms, the best way of reducing smoking in older smokers is to speed the onset of terminal illness.

    This leads us to the second aim of smoking reduction initiatives – preventing young people taking smoking up. It is this audience that has taken on board the various health scare messages displayed on packs of cigarettes and in advertising. It is also deterring this audience from taking up smoking that offers the best chance of hitting the 16% target. As such, it is this audience that the ban on using e-cigarettes in public is most likely to benefit.

    E-cigarettes are undoubtedly healthier than tobacco if you are already a smoker. But if they come to be seen as cool and fashionable to younger people (in the same way that James Dean made smoking look cool in the 1950s) then there is a risk that much of the benefits of the smoking ban will be undone.

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  4. Lee Waters says:

    “The evidence on the effects of e-cigarette vapour on other people is even thinner – to the extent that, at present, it seems to be virtually zero”.

    Have a read of this:
    https://theconversation.com/vapour-from-e-cigarettes-makes-mrsa-bacteria-more-aggressive-26831

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  5. Dan says:

    “What does the Public Health White Paper have to say about achieving the target? Nothing new. There is plenty on more bans and greater regulation of the sale of tobacco products – but nothing to achieve the dramatic increase required in the number of quitters.”

    The author of this piece is showing remarkable ignorance regarding this comment. More bans and greater regulation or tobacco goods is crucial to reducing prevelance and encouring quit attempts. Also add to this behavioural support (Stop Smoking Wales and the Level 3 pharmacy schemes that she has ignored) and tax increases (something that only Westminster can increase at present) as well as prevention like ASSIST and work ASH Wales does and you have a comprehensive strategy that IS reducing numbers of smokers.

    It gets very frustrating when people attack existing services when they do not understand the full picture.

    Perhaps the Bevan Foundation could offer some constructive support as opposed to proposing radical e-cig use when their long terms effects on smokers is not known (although as a reply above states there are real concerns about their safety).

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