This response adds to Nick’s. I will not repeat the things he has said, but will add a few more observations.

1. One of the themes in some of the feedback is that tobacco control people don’t talk to vapers and should. I agree. However, although I have no doubt we could do more, many of us do talk to vapers both informally and through research (our group has recently carried out a series of in-depth interviews with ANDS users).

However, we sometimes come at things from a different perspective. My perspective is as a doctor (formerly working in respiratory medicine) who has seen at first hand the disastrous and tragic health consequences of smoking, often among people who have desperately tried to stop but can’t due to the addictive nature of nicotine. As a public health practitioner I try to work out how I can best reduce smoking (and its health effects) at a population level. I fully understand that some people will have quit smoking through e-cigarettes and that is a good thing for those people, and they will have an extremely positive view of ANDS as a result. However, I want to know if the overall impact of ANDS is positive and how we can take steps to ensure that is the case.

2. Another theme in some of the posts is that by controlling or over-regulating ANDS availability we are working in the interests of the tobacco industry. In response to that I would say that public health people in tobacco control are usually seen as public enemy number one by the tobacco industry, and furthermore much of the criticism of ANDS regulation and policy put forward by tobacco control people comes from directly or indirectly tobacco-industry affiliated people – so that hardly seems to suggest we are doing their work.

3. Going back to the population perspective.

The main areas where ANDS can result in population health benefit is by helping smokers to quit or if smokers fully substitute ANDS use for smoking. If smokers cut down and use a mix of ANDS and smoking to get their nicotine, that will probably result in a small benefit, but most epidemiological evidence suggests cutting down on smoking has only a modest impact on reducing its adverse health effects. Another potential benefit is if youth who would have taken up smoking instead use ANDS. Several of these benefits assume that long term use ANDS, although probably not completely safe has far less health effects than long term smoking, which seems highly likely.

The possible downsides of ANDS on population health include: (i) gateway effect if use of ANDS by youth results in subsequent smoking initiation which would not otherwise have occurred without ANDS use; (ii) smokers who might have quit smoking entirely but don’t because they decide instead to cut down and use ANDS as well &/or find that they can get their nicotine fix by using ANDS in areas where they previously couldn’t smoke (due to smokefree laws etc) – so have no pressing need to give up; (iii) long term health effects of ANDS on health among youth who use ANDS and continue to use ANDS and who wouldn’t otherwise have smoked (see comment above, long term health effects may be relatively minor, though that is not certain); (iv) ‘renormalising’ effect of ANDS (particularly e-cigs that look like tobacco cigs) in making smoking seem more socially acceptable (v) all of the above effects may be magnified by the tobacco industry using ANDS for their own purposes (e.g. through devious marketing strategies) to promote rather than undermine the continuation of tobacco smoking and nicotine use among new generations in society.

The evidence on much of the above is simply not there yet – we do not know what the impact of widespread ANDS use will be among populations in different contexts (types of ANDS available, patterns of ANDS use and smoking, ANDS and tobacco control regulatory contexts etc etc). However, as public health scientists I think we have to be careful and critical about the evidence, admit where we are uncertain and evaluate dispassionately the evidence for or against the population benefits and harms.

So for example, I think the evidence for a gateway effect of ANDS is pretty thin at best (Poland may be an exception), with in many cases (e.g. US) a possibly worrying increase in use of ANDS by youth, but reassuringly a reduction in smoking in the same groups. So the gateway effect is unproven.

However, the evidence cited about the impacts of ANDS on quitting also needs to be viewed with the same critical lens.

For example, several commentators repeat uncritically the assertion that e-cigarettes have resulted in 1.1million people quitting in the UK, 400,000 in the last year. That is based on some projections in a publication by ASH in England from data from the Smokefree Britain surveys of approx. 12,000 adults in 2010 and 2012-2015, in which an estimated 1.1m out of 2.6m e-cigarette users were ex-smokers. 1 The assumption that is made is that everyone of those 1.1m ex-smokers who use e-cigarettes quit smoking only because of e-cigarettes (i.e. they would not have quit otherwise). That is clearly nonsense. Many would have found another way to quit, but a (uncertain) proportion only quit successfully due to e-cigarettes.

However, an estimated 1.4m current e-cigarette users based on the same surveys were still smoking. Of these around 40% gave as the reason that they wanted to stop smoking entirely, which from a public health perspective is promising. However, over 40% said they were using e-cigarettes to help them reduce their smoking but NOT to stop entirely. Another 25% (the totals add up to over 100% presumably because people could give more than one response) said they wanted to continue to smoke and e-cigs allowed them to get nicotine in areas like bars and restaurants where they couldn’t smoke). For the latter two groups, ANDS use may reduce the motivation to quit and quit rates. Indeed a recent paper reported that quit rates among e-cigarette users in the UK who were followed up were LOWER than in non-e-cigarette users (tank users were slightly more likely to quit, but they were only a small proportion of e-cigarette users in this study). 2 So at a population level, unexpectedly, e-cigarette use may reduce quitting among smokers. Findings in other papers that have examined this have had mixed results.

So, in summary there is widespread uncertainty about the overall public health impacts and impacts on smoking of ANDS, but on the current evidence there is probably pretty good grounds to restrict the availability of ANDS to smokers who are most likely to use them to quit, and who have tried and failed to quit with other methods. The case for making them more widely and easily available is not yet clear. However, we should be open to new evidence and the experience of countries with different approaches, and if it becomes clear that the public health benefits are real and reasonably certain, then we need to think again.

References

1. ASK UK. ASH Factsheet on the use of electronic cigarettes (vapourisers) among adults in Great Britain. London: Action on Smoking and Health (England);2015.

2. Hitchman SC, Brose LS, Brown J, Robson D, McNeill A. Associations Between E-Cigarette Type, Frequency of Use, and Quitting Smoking: Findings From a Longitudinal Online Panel Survey in Great Britain. Nicotine Tob. Res. 2015.