Despite evidence suggesting e-cigarettes are far less harmful than smoking, more people than ever believe them to be just as harmful. Professor Linda Bauld discusses the evidence
January is a time for New Year’s resolutions and if you’re one of the world’s one billion smokers, your resolution may be to stop smoking. For some people, this year’s quit attempt might involve an electronic cigarette, and a recent study in England, published in the BMJ, suggested that these devices helped at least 18,000 smokers to stop in 2015 who would not otherwise have done so. That’s very good news, but will there be as many quit attempts in 2017 as there have been in the past with e-cigarettes? I’m not so sure.
Since I last wrote about e-cigarettes in this column one year ago, headlines about the dangers of these devices have continued to appear and show no sign of abating. The result is clear. More people believe today, compared with a year ago, that e-cigarettes are as harmful as smoking. In fact these incorrect perceptions have risen year on year, from fewer than one in ten adults in Great Britain in 2013 to one in four this past summer. Surveys of smokers show similar patterns, with an increasing proportion believing that e-cigarettes are more or equally harmful than tobacco.
Yet we know that these harm perceptions are wrong. There is now very strong evidence, from a range of studies, that vaping – inhaling nicotine without the combustion involved in smoking – is far less risky than smoking cigarettes. Just a few months ago this body of evidence was brought together by the Royal College of Physicians who published an authoritative report analysing dozens of studies and concluded that the hazard to health arising from long term vapour inhalation from e-cigarettes is unlikely to exceed 5% of the harm from smoking tobacco. The RCP, and since then other UK doctor’s organisations such as the Royal College of General Practitioners, have made clear that it is important to promote the use of e-cigarettes, along with other non-tobacco nicotine products (like Nicotine Replacement Therapy such as gum or inhalators) to smokers who are trying to quit. The work of these organisations is underpinned by a consensus statement endorsed by many of the main health charities and public health bodies in the UK. They agree that vaping is safer than smoking, and while these products are not risk free and should not be promoted to children or never smokers, they have a legitimate and positive role to play in tobacco control.
But this consensus is not shared around the world. The regular stream of media scarestories driving harm perceptions often originates in other countries where there is no such view about relative risks. Some media headlines are driven by poor science but others originate from reports by credible organisations who focus on the absolute risk of any e-cigarette use without comparing it to smoking (which is uniquely deadly and kills one in two regular users). 2016 saw at least two major reports of this kind.
In September the World Health Organisation published a report that set out a series of steps on e-cigarette regulation for countries signed up to the Framework Convention on Tobacco Control, a global public health treaty. These options were primarily about banning or severely restricting the sale, distribution and marketing of e-cigarettes. The WHO report was comprehensively critiqued by the UK Centre for Tobacco and Alcohol Studies, but its findings mean that e-cigarettes will continue to be unavailable to millions of smokers in many countries who have banned these devices or are considering doing so.
December 2016 saw the publication of a review authored by the US Surgeon General, which focused on e-cigarette use in young people. This described e-cigarette use as a public health concern, arguing that e-cigarettes are now the most commonly used tobacco product amongst US youth and that nicotine use in any form is unsafe for young people and also pregnant women. While some of the science in the report is accurate, the conclusions endorsing heavy regulation of e-cigarettes were not. The report did not compare the risks of smoking and vaping, failed to make clear that e-cigarettes are not tobacco products, and drew conclusions about nicotine that would also apply to Nicotine Replacement Therapy – which is safe and licensed for use in pregnancy and by young smokers. It also endorsed policies which could deter current smokers from switching to e-cigarettes. American scientists have critiqued data from the USA that provided the basis for the Surgeon General’s report, but it is likely that this publication will contribute to public perceptions that e-cigarettes are dangerous.
These two reports largely ignore the fact that there are already measures in place in many countries (including all of the EU) to protect the public from any risks from e-cigarettes. These include policies like age of sale, limits on advertising and child- and tamper-proof packaging – all important to protect children while still allowing sales to adult smokers and ex-smokers. Concerns about exploding batteries and nicotine poisoning can also be dealt with by following simple safety rules, such as those set out by the Royal Society for the Prevention of Accidents.
I believe that e-cigarettes have huge potential to save lives by providing an alternative to smoking. Yet this can only be realised if we address negative harm perceptions and communicate honestly with the public. Ongoing research can help with this, and 2016 has seen the start of important studies, many commissioned by Cancer Research UK, which will tell us more in the future. We also need to keep our eye on new technology, such as heat not burn tobacco products, which are emerging and about which we know little. Only time will tell whether the UK’s positive approach towards e-cigarettes strikes the right balance between risks and benefits. For now, however, we must do all we can to encourage smokers to try to stop at New Year or any other time. For those trying with e-cigarettes, this is a positive choice that should be supported.