Saturday, 07 November 2015 00:16

By Dr Farsalinos

Shortly after the, now famous, e-cigarette report released by Public Health England (PHE), there has been a coordinated attack by anonymous or signed publications in well-respected academic journals criticizing PHE for releasing a recommendation which, according to their opinion, is not evidence based. More recently, BMJ released an infographic which, indirectly but clearly, implied that there is some financial conflict behind the report.

PHE is basically accused for a simple reason: for “daring” to provide an estimate of e-cigarettes risk compared to smoking based on currently available evidence. If something is wrong with this approach, there is only one way to prove it: provide data that currently available evidence does NOT support this estimate. Unfortunately, none of the critics got even close to providing any evidence to reject the PHE report. Not a single study showing that PHE conclusions are invalid is cited in these articles. Instead, authors have been engaged in a ghost-hunting game of trying to implicate financial conflicts (in some cases even the presence in a conference is considered a financial conflict) which have supposedly influenced the PHE report content. The accusation that 1 of the 185 citations of PHE, which was authored by 12 scientists, included 2 authors with work supported by e-cigarette companies is unprecedented and simply ridiculous (sorry, I tried but could not find a more polite expression). It is a joke to ask authors of a manuscript (report or publication) to search and present every single conflict of interest statement of every author of the studies cited in the manuscript.

This tactic is not only disappointing but also dangerous. It is disappointing because, even though they refer to conflicts, they provide no evidence on how these conflicts have affected the methodology, results and interpretation of study findings. They have accused scientists who are historical figures in tobacco research, such as Karl Fagerström and Riccardo Polosa. This is simply an effort to silence any voice not supporting their tactics, and silence any research which is cannot be used in an aggression against e-cigarettes. It reminds me of a review report that I received for the survey on 19,000 e-cigarette users, in which the reviewer warned the journal that the results were so good that they will be used as a flag by supporters to say how good the e-cigarettes are!! Moreover, this tactic is dangerous because it violates the right of consumers (in this case smokers) to receive objective information on currently available evidence in order to make informed decisions about their harmful habit. This is basically discouraging smokers from trying e-cigarettes in an attempt to reduce or (ideally) quit smoking. The results of this tactic have created a surprising paradox: although over the years we get more and more evidence showing that e-cigarettes are by far less harmful than smoking, smokers have switched their opinion to the opposite side and now the majority believes that e-cigarettes are equally or more harmful than smoking! This is a sad finding (which was recently replicated in a UK survey by ASH UK) because it costs lives.

Many scientists believe that we should be absolutely certain about the effects of e-cigarettes before we make any recommendation. But again, certainty is a very vague term, and it is questionable how it is interpreted by different Public Health people. At the same time, smokers are dying every day and the reduction rate in smoking prevalence is very slow (only 2% decline from 2012 to late 2014 and 2.5% decline since 2009 in Europe).

PHE did its job in the best possible way. They informed the public (smokers) about the current knowledge on e-cigarettes and provided a realistic estimate of risk reduction based on this evidence. As knowledge expands and more evidence becomes available, the risk estimation and relevant recommendations will (and should) be updated. This is exactly how public health should work, and this is exactly what smokers need. I still have not seen anyone proving (or even trying to prove) that the estimate is wrong. Therefore, all critic articles against PHE that have been published so far should simply be ignored.