June 4th, 2014

Arguing about e-cigarettes – a Q&A

Here is a set of questions and answers on e-cigarette science, policy and politics. Please use the comments to suggest other questions, better answers or to pick me up if I’m wrong.

1. What is in the exhaled vapour and is it harmful to other people?

2. Does nicotine cause cancer or other health effects?

3. Does introduction of e-cigarettes have the effect of increasing smoking?

4. Is vaping a gateway to smoking for kids?

5. Are e-cigarettes just ‘renormalising’ smoking?

6. Can e-cigarettes save lives?

7. Do e-cigarette help people quit smoking?

8. Do people who switch continue vaping or move on to quit altogether?

9. The Minister of Health is not convinced of the safety of e-cigarettes – what now?

10. A health organisation has said ‘we just don’t know what’s in them’ – do we really know so little?

11. Shouldn’t people who want to quit smoking use licensed smoking cessation medicines like NRT?

12. Shouldn’t we just ban vaping indoors as we have done with smoking?

13. E-cigarette advertising is targeted at children and should be banned

14. Nicotine is a powerful poison and needs to be strictly controlled or outlawed

15. The tobacco industry is involved and they will want to force smokers to keep smoking

16. We are going to clamp down on e-cigarettes in hospitals

17. A doctor is saying nicotine is as addictive as crack cocaine, and that tobacco is just like a syringe for nicotine

18. The long term effects of inhaling e-cigarettes are not known. Should they not be restricted until it is known they are safe for continuous use?

19. E-cigarettes should be regulated as medicines to guarantee safety, quality and efficacy

20. What if the critics of e-cigarettes are wrong?

21. “E-cigarettes contain [rat poison][weed killer][anti-freeze][carcinogens][insert scary sounding chemical here]”

22. The ultimate public health aim is to remove reliance on nicotine entirely

23. New Those flavours are there to attract children

Appendix. How well is Ireland doing on tobacco and health?

1. What is in the exhaled vapour and is it harmful to other people?

In the exhaled vapour there’s some vapour base (an ‘excipient’ like propylene glycol), a little nicotine, some water vapour and some flavours that might impart an aroma. There may be some breakdown products or traces of contaminants. The things that lead to concern about second hand tobacco smoke are either absent, undetectable or present in very low concentrations. The most comprehensive review so far concludes that active vaping poses near negligible risk, and that second hand exposure would be ‘orders of magnitude’ less.:

Current state of knowledge about chemistry of liquids and aerosols associated with electronic cigarettes indicates that there is no evidence that vaping produces inhalable exposures to contaminants of the aerosol that would warrant health concerns by the standards that are used to ensure safety of workplaces. However, the aerosol generated during vaping as a whole (contaminants plus declared ingredients) creates personal exposures that would justify surveillance of health among exposed persons in conjunction with investigation of means to keep any adverse health effects as low as reasonably achievable. Exposures of bystanders are likely to be orders of magnitude less, and thus pose no apparent concern. (emphasis added) (Burstyn I, 2013) Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks

2. Does nicotine cause cancer or other health effects?

No. There is no evidence that nicotine causes cancer – and it is really for those that make the claim to show that there is. It is possible that nicotine is unhelpful in treatment or recovery if you already have cancer. It’s the smoke – the smouldering particles of organic material and hot toxic gases – that does the damage. Professor John Britton, who is Director of the UK Centre on Tobacco and Alcohol Studies and heads the Royal College of Physicians Tobacco Advisory Group compares the health risks of nicotine to caffeine.

“Nicotine itself is not a particularly hazardous drug,” says Professor John Britton, who leads the tobacco advisory group for the Royal College of Physicians. “It’s something on a par with the effects you get from caffeine. “If all the smokers in Britain stopped smoking cigarettes and started smoking e-cigarettes we would save 5 million deaths in people who are alive today. It’s a massive potential public health prize.” (BBC, Feb 2013)

Like caffeine, nicotine has effects on the cardiovascular system: raising heart rate and blood pressure. There is also concern that it has impact on foetal development. The harms caused by smoking have often been confused with nicotine and it is inherently hard to study the impact of nicotine itself in smokers because there are so many other substances the smoker is exposed to at the same time. Fortunately, there has been extensive research into the health risks of nicotine because of its use in a licensed medical product, NRT. The Royal College of Physicians Tobacco Advisory Group surveyed the literature in 2007 (RCP, Harm reduction in nicotine addiction) and concluded the chapter on medicinal nicotine:

Extensive experience with nicotine replacement therapy in clinical trial and observational study settings demonstrates that medicinal nicotine is a very safe drug.

Adverse effects are primarily local and specific to the mode of delivery used.

NRT does not appear to provoke acute cardiovascular events, even in people with pre-existing cardiovascular disease.

There is no direct evidence that NRT therapy is carcinogenic or influences the risk of other common smoking-related diseases in humans.

Evidence on the safety of NRT during pregnancy is limited, but suggests that NRT does not increase the risk of major developmental anomalies or reduce birth weight. However, NRT may increase the risk of minor musculoskeletal anomalies. Further evidence on these effects is needed.

Evidence on the safety of long-term use of NRT is lacking, but there are no grounds to suspect appreciable long-term adverse effects on health.

In any circumstance, the use of NRT is many orders of magnitude safer than smoking

Health benefits? There is also evidence nicotine may have health benefits, for example in reducing weight, protecting against Parkinson’s disease and improving cognitive function – see CASAA’s page on this for sources.

Detriment of withdrawal and craving. Withdrawal from nicotine use may be disruptive and unpleasant – and and such has a negative effect on health and wellbeing. So use of nicotine in people who quit smoking has the health benefit of avoid at least some of the withdrawal and craving. That is one reason why the prospects for e-cigarettes are so promising: it can provide many of the benefits people perceive in smoking, but with few of the impacts, while avoiding the unpleasant experience of quitting completely – and at lower cost. That value proposition gets stronger as each month goes by.



3. Does introduction of e-cigarettes have the effect of increasing smoking?

No – there is no evidence to support this. People who don’t like vaping for other reasons try to use this argument to suggest that a product that is many times less risky than cigarettes can somehow become more dangerous, because it somehow prevents people from quitting. The same sort of people used the same arguments were used to get Swedish snus banned in the EU in 1992, even though it is probably 98-99% less risk. The snus ban wasn’t applied in Sweden, which now has by far the lowest rates of smoking in the EU and lowest rates of smoking related disease. In Sweden, people used snus to quit smoking, to displace cigarettes or instead of starting to smoke (see letter from experts: why is EU banning Europe’s most effective response to smoking?). On e-cigarettes, the survey data is now coming in and showing pretty much the same thing – take this one The Guardian reporting on the survey by ASH (UK)

But Ash’s survey, carried out by YouGov, suggests this is not happening and that people are using e-cigarettes to kick their tobacco habit instead. “The dramatic rise in the use of electronic cigarettes over the past four years suggests that smokers are increasingly turning to these devices to help them cut down or quit smoking. Significantly, usage among non-smokers remains negligible,” said Deborah Arnott, Ash’s chief executive. (Guardian)

4. Is vaping a gateway to smoking for kids?

No, despite a great deal of hype from the US, the facts are very different. Although there is a rise in e-cigarette use among school age adolescents, that does not prove anything bad is happening – it simply mirrors what is going on in adult society. Whether it is harmful depends what you think would have happened in the absence of e-cigarettes. It is quite possible that e-cigarette use is displacing smoking in adolescents. Even where they have never smoked it might be acting as an alternative to taking up smoking. For there to be any real harm, you would need to show that students were taking up vaping and then going on to develop a life-long smoking habit, because of the vaping. In fact in the data presented from the US there were much more encouraging signs: e-cigarette use was a small fraction of the smoking rate among school students; the rise of e-cigarette use coincided with a much larger drop in smoking; and e-cigarettes use was concentrated among those already smoking. Here is the full picture in graphic form, and you can read more discussion on the bogus claims for gateway effects in my ‘Cease and desist’ letter to scientists trying to perpetrate this fraud and a background discussion on ‘gateway effects’: we need to talk about the children: the gateway effect examined.





5. Are e-cigarettes just ‘renormalising’ smoking?

The people who claim this need to explain carefully how they think one activity can normalise another, especially when these alternatives involve products in competition. It is more likely, and should be assumed in the absence of evidence to the contrary, that vaping normalises vaping, which is an alternative to smoking – and therefore normalises not smoking. High level support for this comes from one of the world’s experts in smoking cessation, based on UK survey data:

Evidence conflicts with the view that electronic cigarettes are undermining tobacco control or ‘renormalizing’ smoking, and they may be contributing to a reduction in smoking prevalence through increased success at quitting smoking (Professor Robert West: Trends in e-cigarette use, presentation to European Conference on Tobacco or Health)

6. Can e-cigarettes save lives?

This is a matter of simple logic. If smoking is dangerous and may kill potentially one billion people in the 21st Century, then if people substitute cigarettes for products that do not have the main thing that causes the risks (burning organic material and inhalation of smoke) then they will be at greatly reduced risk. It’s hard to know exactly what the risks are relative to smoking – some people can see no obvious pathway whereby they would cause death. One expert ‘multi-criteria decision analysis’ put the health risks at around 1% (or 3% if you include ‘addiction’ as a health risk, which is a debating point). This is how they compare different nicotine products (Nutt D et al, 2014) – e-cigarettes are included in ENDS – electronic nicotine delivery systems:

Fifty three scientists and other experts wrote to the WHO Director General, Margaret Chan to say in their letter of 26 May 2014:

There are now rapid developments in nicotine-based products that can effectively substitute for cigarettes but with very low risks. These include for example, e-cigarettes and other vapour products, low-nitrosamine smokeless tobacco such as snus, and other low-risk non-combustible nicotine or tobacco products that may become viable alternatives to smoking in the future. Taken together, these tobacco harm reduction products could play a significant role in meeting the 2025 UN non-communicable disease (NCD) objectives by driving down smoking prevalence and cigarette consumption. […] The potential for tobacco harm reduction products to reduce the burden of smoking related disease is very large, and these products could be among the most significant health innovations of the 21st Century – perhaps saving hundreds of millions of lives. The urge to control and suppress them as tobacco products should be resisted and instead regulation that is fit for purpose and designed to realise the potential should be championed by WHO.

7. Do e-cigarette help people quit smoking?

Yes, it looks like it, and in the real world too – not just in the artificial world of clinical trials. In fact they appear to be more successful than established smoking cessation products like NRT. A recent study found that people were 60% more likely to succeed using e-cigarettes.

People attempting to quit smoking without professional help are approximately 60% more likely to report succeeding if they use e-cigarettes than if they use willpower alone or over-the-counter nicotine replacement therapies such as patches or gum, reveals new research published in Addiction.

Brown, Beard, Kotz, Michie & West, ‘Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study’, Addiction, May 2014.

ASH’s 2014 survey showed that about a third of users were now ex-smokers – 700,000 in the UK or about 7% of the smoking population – implying that many people are successfully quitting.

+ An estimated 2.1 million adults in Great Britain currently use electronic cigarettes.

+ About one third of users are ex-smokers and two-thirds are current smokers.

+ The main reason given by current smokers for using the products is to reduce the amount they smoke while ex-smokers report using electronic cigarettes to help them stop smoking.

People should also take the trouble to listen to the thousands of accounts of the experiences of people switching. These are often dismissed as anecdote – but you hear the same message over and over again. Take this for example:

I smoked for 45 years and tried every NRT product available, none of them worked. I continued to smoke even though my health was getting worse, resulting in COPD and using oxygen daily. September 2011 I discovered e-cigarettes and they worked. It was like someone handed me a miracle. In less than a week I stopped using regular cigarettes. I haven’t had a tobacco cigarette since. I wish the MP’s and MEP’s would understand how much e-cigarettes have helped thousands of people just like me. See many more testimonies like this in my posting: Where is the empathy, where is the humility?

8. Do people who switch continue vaping or move on to quit altogether?

We will have to wait longer for the data to come in on that, given that e-cigarettes are relatively new to most users. The better question is whether it matters. If the health risk of using a vapour product is very much lower than smoking, then the important transition is from smoking to not smoking. Whether that means continued vaping or complete cessation of nicotine is a second order concern. One of the advantages of vaping is that it is a much easier transition than quitting completely: it is easier to do in the first place because it does not involve overcoming nicotine dependence and so withdrawal and craving are greatly reduced. It may also mean relapse is less likely.



9. The Minister of Health is not convinced of the safety of e-cigarettes – what now?

This is probably literally true: he is not convinced. But that doesn’t mean he has made a competent assessment or is applying the same standards he would apply to other risks in this field. What the minister needs to say is what would convince him. Nothing is ever entirely safe – we usually judge whether risks are tolerable, given the benefits and demand for the product. By way of comparison, I wonder if he is convinced of the safety of, say, Varenicline ( a stop smoking medical treatment marketed as Champix or Chantix)? I am not saying people shouldn’t use it by the way, just that its safety has been judged on a risk-benefit basis. You certainly couldn’t call it ‘safe’.

The list of known-knowns, the noted side-effects, is long and unpleasant:

And the list of serious concerns (the known unknowns) is quite troubling and these concerns remain unresolved as these papers from the US Food and Drug Administration show:

The health minister needs to examine his conscience and decide if all his negativity, doubts and worries are in fact discouraging people who smoke from trying an e-cigarette, and so supporting the cause of continued cigarette use. It is possible he has made himself one of the most powerful friends and allies of the tobacco industry, though without actually realising it. He led the European Council push to have e-cigarettes regulated as medicines, a move which would have virtually destroyed the existing industry and handed what remains to Big Tobacco. In my view health ministers, lead by the James Reilly of Ireland displayed a particularly trite and cynical form of negligence. See: Negligence in tobacco policy. The same criticism can be levelled at the rest of the public health establishment – exceedingly complacent with hugely exaggerated concerns about minor or hypothetical risks and apparent indifference to huge potential for health gains.



10. A health organisation has said ‘we just don’t know what’s in them’ – do we really know so little?

They’ve been on the market since 2008, and its now 2014. What have they been doing all this time? In fact there is quite a lot of evidence about these products (see PubMed), if they bothered to look and to have an open mind. I recommend this review: A fresh look at harm reduction the case for the electronic cigarette, Polosa et al 2013. Critics should start be reading the Igor Burstyn review: peering through the mist – and I would advise anyone encountering this argument by ignorance to ask what they think of Burstyn’s review. None of this is to say that some regulation isn’t justified to create good basic standards and to improve consumer confidence. The trouble is that many of those saying they don’t know, actually don’t want to know. They want ignorance to be the basis of fear and fear to be the basis of coercive policies.



11. Shouldn’t people who want to quit smoking use licensed smoking cessation medicines like NRT?

NRT may help some people, but what if other people don’t want to quit nicotine or choose not to use NRT or other medications? E-cigarette use isn’t about quitting it’s about continuing – in this case continuing to use the legal recreational drug nicotine – in a way that is very much less hazardous to health. The correct comparator is smoking, not NRT. We should remember that snus has huge benefits in Sweden without ever being approved or highly regulated by anyone – it works so well because it substitutes for smoking. Regulating these products as medicines would kill them off – effectively raising costs, crushing innovation, killing the buzz and dramatically reducing the range of products available. The main effect of medicine regulation would be to destroy most of the industry, leaving what’s left to the deep pockets of the tobacco industry. We also have evidence that people using e-cigarettes have more success at quitting than people using NRT – so why would an ethically sound health professional recommend the less effective option?



12. Shouldn’t we just ban vaping indoors as we have done with smoking?

No, unless and until there is evidence of harm, it is not appropriate to use the coercive powers of the law. If someone want to open a bar that welcomes vapers then the only reason for the law to stop them is if someone else is harmed – or at least there is no prospect of a material risk. The law shouldn’t be used to regulate consumer choice, good taste, aromas, aesthetics. The idea that it can hide vaping from view is absurd – people will be outside a building rather than inside. Owners and operators should make the decisions as they are best placed to weigh different social, economic and wellbeing issues. Note that allowing vaping can have health benefits: it may encourage smokers to switch and prevent vapers relapsing to smoking. It adds to the value proposition of e-cigarettes, relative to smoking.



13. E-cigarette advertising is targeted at children and should be banned

No it isn’t – and it is a huge evidence-free defamatory accusation to assert that manufacturers are targeting kids. No manufacturer is targeting kids (and if they are they have been a miserable failure, given how few kids vape!) for two main reasons: (1) they’d be suicidally stupid to try it; (2) they have absolutely no need to incur the vast reputational risks involved – the world tobacco market is $700-800 billion, vapour products so far have less than 1% of that. Their value proposition is strongest for existing smokers who want a change or have growing concerns about their own smoking. Tobacco advertising is banned in the EU because smoking kills over 500,000 people annually in the EU – no such justification can be made for e-cigarettes. In fact, it is much more likely that e-cigarettes will have a negative death toll – a protective effect on smokers. Advertising is critical in the e-cigarette world and much of it is powerful persuasion against smoking: it is necessary to communicate with smokers; to incentivise, communicate and reward innovation; to build trusted brands; to create buzz… all of this helps to bring smokers over to vaping.

It is possible that some non-smokers may be persuaded to vape or ex-smokers decide to take it up – it would be foolish to claim this is impossible. That creates very little health risk in itself and has to be set against potential huge health benefits to smokers who switch. There are no real absolutes – it’s a matter of being proportionate about risks and benefits.



14. Nicotine is a powerful poison and needs to be strictly controlled or outlawed

Huge hype has been generated by the New York Times, which discovered a ‘surge’ in nicotine related poisoning events:

… the number of cases linked to e-liquids jumped to 1,351 in 2013, a 300 percent increase from 2012, and the number is on pace to double this year, according to information from the National Poison Data System. (NYT 23 March 2014)

Yes, that sounds very bad… but it turns out this is a rapid rise in a small number compared to other poisoning calls in the US:

Source: 2012 Annual Report of the American Association of Poison Control Centers ’ National Poison Data System (NPDS): 30th Annual Report

Here’s the truth:

The reports of poisonings are not poisonings, but phone calls made by people worried about poisoning. Worries are increased by hype and hostile media commentary and may be stoked up by public health alarmism.

The fear of nicotine toxicity is grounded on 19th Century science which has recently been reappraised (see Mayer B: How much nicotine kills a human? Tracing back the generally accepted lethal dose to dubious self-experiments in the nineteenth century). On thye basis of this assessment we can conclude that nicotine is 10-20 times less toxic than widely assumed.

If swallowed nicotine almost always causes vomiting – actual serious or fatal poisonings are very rare and hard to pin down with certainty

We have many products in the household that are dangerous: bleach, cleaning fluids, flammable liquids, medicines etc – we control the risks of these by having tamper proof packaging, warnings and effective labelling

There are international standards available: for example ISO 8317 on Child Resistant Packaging or the European Union’s CLP Regulation.

15. The tobacco industry is involved and they will want to force smokers to keep smoking

The appalling history of Big Tobacco should give everyone concern – but not to the point of blindness and paranoia. These companies are interested in taking market share from each other in the combined profit from tobacco and e-cigarettes. They would happily get it all from e-cigarettes if they could. To defend their total business the tobacco companies will need to develop top quality products that appeal to smokers, or else someone else will. Their incentives are not to defend smoking but to retain their customers – if that involves them stopping smoking, then so be it. More on this in my reply to an article on the tobacco industry. Jonathan Fell, the former tobacco analyst at Merrill Lynch, Morgan Stanley and Deutchse Bank says in a debate with prominent anti-e-cigarette activist:

The idea of tobacco companies selling lower-risk products might be anathema to some, but what else could a responsible management and board do? It’s been an effective public health strategy to demonise the tobacco industry in the past, but many tobacco control advocates seem be in danger of believing their own propaganda on this point. Tobacco industry boards and managements are much like the boards and managements of any other consumer business. A product which is potentially beneficial when sold by one company doesn’t become a bad product just because it’s sold by someone you don’t like.

If people don’t like Big Tobacco, they don’t have to buy from them. The only institution that could allow them to abuse the market is a regulator – by raising barriers to entry that only they can match and so giving them control. Something they seem determined to do in many jurisdictions.



16. We are going to clamp down on e-cigarettes in hospitals

These are problems for the health establishment, not problems with e-cigarettes. E-cigarettes are not medicines and as long as HSE talks about them as though they are, they are missing the point. They need to think more carefully of the welfare of people in hospital, who may be there precisely because they smoke. It could be a great opportunity to convert them to something much less dangerous and so make an important preventative intervention as well as help them feel better while in hospital. There may be a case to allow vaping on health and welfare grounds and to start hardened smokers (yes, the ones you tend to find in hospital) on a journey to stopping smoking, via vaping. There is definitely no case to be even more prohibitive than for smoking.



17. A doctor is saying nicotine is as addictive as crack cocaine, and that tobacco is just like a syringe for nicotine

This doctor has no basis for the comparison with crack cocaine. Crack is the free base form of cocaine. Even for cocaine in its non-free based form the claim was debunked more than 20 years ago.

…we consider several lines of evidence, including patterns of mortality, physical dependence potential, and pharmacologic addiction liability measures. Within each line of evidence, we compare nicotine with cocaine. We conclude that on the current evidence nicotine cannot be considered more addicting than cocaine. Both are highly addicting drugs for which patterns of use and the development of dependence are strongly influenced by factors such as availability, price, social pressures, and regulations, as well as certain pharmacologic characteristics. (Henningfield et al 1991 Is nicotine more addictive than cocaine?)

Nicotine in itself is not that addictive, it matters how fast nicotine is delivered and whether there are sensory and behavioural reinforcements. Smoking may also introduce other psychoactive substances (MAOIs) alongside nicotine. It is more accurate to say that smoking is addictive. One of the foremost experts in nicotine, Karl Fagerström, explains it as follows on this blog 9 May 2014 entry:

As much as there is a continuum of harm from nicotine containing products there is also a continuum of dependence. Dependence is of course also part of the total harm. We know of no nicotine patch use among people who have never smoked that has resulted into compulsive use i.e. dependence. There are cases, although only a few, of gum use by never smokers that has resulted in dependence or transition to tobacco use. Thus, nicotine products, without involvement of tobacco, seem to have a dependence potential close to caffeinated drinks. […] I would expect e-cigarettes to be generally less addictive than tobacco cigarettes because they mostly deliver nicotine more slowly and they do not deliver the other psychoactive chemicals. I would expect them to be more addictive than other pure nicotine products because they involve a repetitive activity and sensations that have been linked to smoking.

Even so, the question is not that relevant. The most important point for a doctor is that nicotine can be addictive or in smoked form very addictive, but in itself, isn’t that harmful. It doesn’t cause intoxication or induce strong tolerance, requiring ever larger doses. In the form of smoking it is very harmful to health in the long run. So if people are using nicotine – a legal widely available recreational drug – then they would be far better using it from an e-cigarette than by smoking tobacco cigarettes.

Other doctors are more sensible:

For the record: I wholeheartedly support use of E-cigs and think banning them would sound the death knell for smokers everywhere #EUecigBAN — Dr Christian Jessen (@DoctorChristian) December 15, 2013

And Dr Chris Steele discusses e-cigarette on ITV’s breakfast programme – sound advice:

18. The long term effects of inhaling e-cigarettes are not known. Should they not be restricted until it is known they are safe for continuous use?

It is a statement of the obvious to say that the long term effects are not known – they can’t be known with certainty until the long term has passed and data is available to study. The seminal study on smoking and health is called: Mortality in relation to smoking: 50 years observations on male British doctors because it takes that long to build up a comprehensive picture. E-cigarettes have been in use for only a few years and their use is evolving all the time – we don’t even know yet if people will use them over several decades, as with smoking. But this lack of knowledge about the future is common in policy-making. The approach used is rely on what we do know, which is far from nothing – rather than complaining that we don’t know everything. So opponents of e-cigarettes talk as though they have just arrived from Mars (the e-cigs), but in fact we know quite a lot. From what we do know, we can make a reasonable risk assessment. So far, we can say:

We are certain that there is no combustion. This is the most important difference and matters a lot because it is products of combustion do the a lot of the damage in cigarette smoke

We can look for toxic substances that may cause serious disease over time – we find these are either not present at all, or present in very low concentrations compared to cigarette smoke or workplace limits

No serious acute effects have emerged (you would know about it if they had!) and most users report considerable improvement in short term health and wellbeing

This is not to say there are no grounds for concern – for example we might be carefully study two potential sources of risk: (1) breakdown products arising from running at high temperatures; (2) the complex chemistry of natural flavourings. However, there is so far no credible theory that gives cause for alarm about these.

However, we do know with certainty that smoking is harmful. There is a great danger that in restricting e-cigarettes because of uncertainty, we will end up with more smoking, which are certain is harmful. So the so called precautionary principle (discussed here) has to look not only at the risk of e-cigarette use but also at the risk of restrictions on e-cigarette use and the potential to cause more smoking as a result – it isn’t just a safe one way cautious bet. So the right way to handle the long term uncertainty is:

keep studying the physics and chemistry of e-cigarettes and liquids

develop and test theories by which harm may be caused

keep up epidemiological surveys on the user population

set standards for products that make sure they are reasonably safe and high quality

be flexible enough to intervene and change policy to introduce restrictions if problems emerge

recognise that any problems may be confined to narrow circumstances (particular flavours, or devices) so target restrictive regulation on them – not the whole category

remember that restrictions on e-cigarettes may cause more smoking and thereby do more harm than good.

19. E-cigarettes should be regulated as medicines to guarantee safety, quality and efficacy

This is about the worst idea for regulating e-cigarettes that anyone has ever had. The basic problem is that this regulatory framework is there to control quality, safety and efficacy of medicines. E-cigarettes are not medicines, but alternative ways of taking the legal and widely used recreational drug nicotine with many superior features compared to smoking. The main problems that will arise include:

Consumer choice severely limited . A dramatic contraction in the number and range of products on the market – the high costs and burdens of applying will not be worthwhile for most products

. A dramatic contraction in the number and range of products on the market – the high costs and burdens of applying will not be worthwhile for most products Consumer priorities ignored. No sign of any consumer demand for it – the only people who want it are health activists. Consumers want fun, frivolous, appealing products that are safe enough.

No sign of any consumer demand for it – the only people who want it are health activists. Consumers want fun, frivolous, appealing products that are safe enough. Supply chain disrupted or destroyed . Major impacts on the supply chain, that would need to upgrade to pharmaceutical standards of manufacturing

. Major impacts on the supply chain, that would need to upgrade to pharmaceutical standards of manufacturing More effective products barred . Tendency to commodify the market – yet the most successful products from a health perspective are the vapour, mods and tank type products – exactly the ones that fare worst under this system

. Tendency to commodify the market – yet the most successful products from a health perspective are the vapour, mods and tank type products – exactly the ones that fare worst under this system Brake on innovation. Slower and less imaginative innovation – with high costs and burden of achieving approvals, companies will be cautious

Slower and less imaginative innovation – with high costs and burden of achieving approvals, companies will be cautious Deadweight costs. Higher compliance costs, unnecessary restrictions, heavy burdens will raise costs, constrain product design and divert management focus away from consumer to the regulator

Higher compliance costs, unnecessary restrictions, heavy burdens will raise costs, constrain product design and divert management focus away from consumer to the regulator Banality . Tendency to eliminate buzz and excitement and become boring and bland – see NRT packaging and marketing for example

. Tendency to eliminate buzz and excitement and become boring and bland – see NRT packaging and marketing for example Recreate tobacco oligopoly . Creates barriers to entry, reduces competition and plays directly into the hands of the biggest companies

. Creates barriers to entry, reduces competition and plays directly into the hands of the biggest companies Illegal. If forced on companies, it would be unlawful – e-cigarettes do not legally fall under the definition of a medicine as repeated judgements in Europe and US have shown

I could go on… and in fact have – 10 reasons not to regulate e-cigarettes as medicines and The case for regulating e-cigarettes as medicines: a line by line examination



20. What if the critics of e-cigarettes are wrong?

This is the question they have to answer. They are in positions that command trust and that people look to for advice. If they are making these arguments with no evidence and poor judgements where there is uncertainty they may be inadvertently increasing smoking and protecting the cigarette business. A group of 53 scientists recently wrote to the WHO suggesting ten principles (see my reader’s guide to this letter for more). The third highlights this risk:

3. On a precautionary basis, regulators should avoid support for measures that could have the perverse effect of prolonging cigarette consumption. Policies that are excessively restrictive or burdensome on lower risk products can have the unintended consequence of protecting cigarettes from competition from less hazardous alternatives, and cause harm as a result. Every policy related to low risk, non-combustible nicotine products should be assessed for this risk.

21. “E-cigarettes contain [rat poison][weed killer][anti-freeze][carcinogens][insert scary sounding chemical here]”

We often hear claims that e-cigarettes contain something nasty and scary sounding. Actually no they don’t – other than as a propaganda. These claims are generally based on two types of error (sometime both):

1. Chemical illiteracy – for example confusing propylene glycol (e-cigarette vapour base liquid) with ethylene glycol (anti-freeze).

2. Confusion of hazard and risk – nicotine is a natural pesticide, but is not poisonous in e-cigarettes (or cigarettes). The key concept to understand is that the dose makes the poison. Whether a chemical is hazardous is a property of the chemical. Whether it poses a risk to health depends on the hazard and the exposure. We are exposed to hazardous chemical all the time – in all cooked food, ambient air, drinking water. Take coffee. It is literally the case that we do not know what is in each cup – the roasting process is chemically uncontrolled and creates many de novo chemicals, including numerous carcinogens – see this statement from one of the pioneers in the field:

Over a thousand chemicals have been reported in roasted coffee: more than half of those tested (19/28) are rodent carcinogens. There are more rodent carcinogens in a single cup of coffee than potentially carcinogenic pesticide residues in the average American diet in a year, and there are still a thousand chemicals left to test in roasted coffee.

The causes and prevention of cancer: the role of environment (Ames BN, Gold LS 1998).

22. The ultimate public health aim is to remove reliance on nicotine entirely

That is the ultimate aim of some campaigners is the complete cessation of nicotine use (see this article). There are four objections to this reasoning:

1. Libertarian. Nicotine is a recreational drug that many people like using and does no harm to others through toxicity or intoxication, nor does it impose costs through the health care system. It is the individual, not the public health authorities, that should determine what the ‘ultimate aim’ is for them personally.

2. Utilitarian. Nicotine is a functional legal recreational drug that people like using, or in the case of many ex-smokers miss using. If nicotine use is no longer conflated with the significant harm caused by smoking then what’s the objection? Over time we will come to be seen as more like having a strong coffee in the morning or a glass of wine with dinner. We do not generally strive for zero drug use in society, and drug use is a feature of human society going back millennia.

3. Pragmatic. The switch from smoking to vaping is the crucial transition for health and harm reduction purposes. The additional step from vaping to abstinence provides little additional health benefit, but comes with welfare costs including withdrawal and craving and extra risks, including relapse to smoking. In some ways, vaping may be a form of ‘inoculation’ against relapse to smoking.

4. Professional. Public money is spent on public health through the NHS, local authorities and on supportive bodies like ASH. Public spending should meet tests of ‘value for money’ (outcomes that justify expenditure) and ‘regularity’ (some sort of authority for taking action [see bible of public spending: Managing Public Money]. There is no basis against these criteria for spending public funds on abstinence objective – and it is why NHS Stop Smoking Services should not consume public funds helping people to quit vaping rather than smoking. That is down to the individual.

If publicly funded ‘public health’ wants to become a temperance movement it needs to show that abstinence leads to harm reduction that provides value for money consistent with norms for public spending. If it is drawing on charitable funds (eg. from cancer or heart charities) it needs to ensure that abstinence – rather than harm through cancer or heart disease – is consistent with the relevant charitable objectives.

23. Those flavours are there to attract children

The wide range of flavours are there to meet demands from adult smokers. No-tobacco flavours are important to ex-smokers in sustaining a long term migration away from tobacco use, and for preventing relapse to smoking. They form an interesting part of the value proposition to smokers: personalisation, experimentation, connoisseurship and fun. A the E-cigarette forum survey of vapers showed flavours in widespread use by adults, with fruit flavours dominating. 65% of vapers (self-selected from this site’s large base of engaged users) report that flavours have been important to them in the transition from smoking.

It is also asserted without evidence that adolescents prefer ‘childish’ flavours. Why would they? Part of the purpose of using an e-cigarette is to emulate adult behaviours – it cannot simply be assumed that they will adopt flavours that reinforce childishness. A further problem with many of the assertions made about flavours regards intent – the idea that e-cigarette manufacturers are ‘targeting kids’ is offered without any substantiation, yet it is a serious allegation often made and far too lightly. Perhaps one day a defamed e-cigarette maker will go to court to demand some evidence to back this lazy smear.

See article by Jacob Sullum.

Appendix. How well is Ireland doing on tobacco and health?

Badly. Very badly. 38th out of 41 badly. Ireland’s public health establishment and government talks the talk with quite some swagger, and even asserts that it will be smoke free by 2025. In fact in 41 countries surveyed by the OECD it ranked 38th (see graphic at the end of this post). So Irish vapers should not be taking any criticisms from them: they’ve basically failed in their own self-declared mission and should be listening, not lecturing, right now. Ireland has one of the highest smoking prevalence rates and one of lowest rates of decline in smoking in the OECD between 2000 and 2011. It is common to claim that traditional tobacco control is just on the cusp of a great victory, and that e-cigarettes are putting all that at risk. Not so really.

This failure has not caused much pause for reflection in the Irish public health establishment, and in fact Ireland is applauded in tobacco control for having the best policies (second only to the UK) – see the European Cancer Leagues tobacco control score card.

So if Ireland ranks high in policy activity but low in smoking results, what does that tell us about: (1) the quality of the policies; (2) the values and purpose of the tobacco control community.