tag:theconversation.com,2011:/ca-fr/topics/e-cigarette-regulation-19888/articlese-cigarette regulation – La Conversation2019-01-03T11:01:24Ztag:theconversation.com,2011:article/1090982019-01-03T11:01:24Z2019-01-03T11:01:24ZVaping: smokers who switch could be less likely to use cigarettes again<figure><img src="https://images.theconversation.com/files/252250/original/file-20190102-32121-1x8twti.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>One of the most common New Year’s resolutions is to stop smoking. Quite rightly so, considering smoking is the biggest leading, preventable cause of death, worldwide. In fact, tobacco is the only legally-available product that <a href="http://www.eurekaselect.com/72217/article">kills up to one in every two users</a>, when used as intended.</p>
<p>There are a number of ways to stop smoking. But the most common include going “cold turkey”, the use of medication – usually offered by doctors and stop smoking services – or the <a href="https://theconversation.com/vaping-how-safe-is-it-101266">switch to e-cigarettes</a>. </p>
<p>There’s little doubt that e-cigarettes, more commonly known as “vapes”, <a href="https://www.gov.uk/government/news/phe-health-harms-campaign-encourages-smokers-to-quit">are less harmful than conventional cigarettes</a>. But discussions around <a href="https://theconversation.com/were-unsure-if-e-cigarettes-are-harmful-but-it-still-makes-sense-to-restrict-them-55777">exactly how harmful e-cigarettes could be</a> to users and those within close proximity, are still ongoing. </p>
<p>Unlike research conducted into the effects of smoking tobacco, very little is understood about any long-term health effects relating to the use of e-cigarettes. This is mainly due to the fact they are a relatively new product and researchers struggle to study people who use e-cigarettes that have never smoked conventional cigarettes.</p>
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Read more:
<a href="https://theconversation.com/fake-e-cigarette-liquid-is-putting-vapers-at-risk-heres-how-we-can-tackle-the-fraud-100916">Fake e-cigarette liquid is putting vapers at risk – here's how we can tackle the fraud</a>
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<p><a href="https://www.gov.uk/government/news/phe-health-harms-campaign-encourages-smokers-to-quit">Public Health England reports</a> that e-cigarettes are approximately 95% less harmful than conventional cigarettes. However, professor John Newton, Public Health England’s <a href="https://www.gov.uk/government/news/phe-health-harms-campaign-encourages-smokers-to-quit">director of health improvement, says</a>: </p>
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<p>Our position on the figure is that it is the best available published estimate. It is a useful figure, but it is not a precise scientific estimate.</p>
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<p>Although e-cigarettes do not contain some of the more dangerous components of conventional cigarettes – such as tar or carbon monoxide – some potentially harmful products may be present, including certain heavy metals. The lack of regulation in the industry makes the work of researchers more difficult, as differences between brands can have an impact on any research findings. </p>
<h2>Gaps in knowledge</h2>
<p>It is estimated that 2.9m people in the UK regularly use e-cigarettes according to a recent <a href="https://publications.parliament.uk/pa/cm201719/cmselect/cmsctech/505/505.pdf">parliamentary report</a>. And in 2016, <a href="https://www.gov.uk/government/publications/tobacco-control-plan-delivery-plan-2017-to-2022">The Tobacco Control Plan</a> – an initiative from the Department of Health and Social Care which aims to reduce smoking in England – estimated over 470,000 people were using e-cigarettes as a way to stop smoking.</p>
<p>However, the <a href="https://publications.parliament.uk/pa/cm201719/cmselect/cmsctech/505/505.pdf">report</a> does not go on to say how many of those using e-cigarettes as an aid to quit smoking achieved this goal. Nor is there yet a true picture of the effects e-cigarettes can have on the small veins and arteries – in both smokers and “second-hand” smokers. These are fundamental knowledge gaps.</p>
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<p>I am currently leading a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5379660/">study at Sheffield Hallam University</a> that looks at the benefits and risks of using e-cigarettes to stop smoking. We focus on cardiovascular health, looking at the effect on small veins and arteries. </p>
<p>With funding from Heart Research UK, study participants have their progress monitored over a six-month period. The participants are split into three groups: one using nicotine rich e-cigarettes, another which is given nicotine-free e-cigarettes, and a third group which is provided with nicotine replacement therapy with the support of Sheffield’s stop smoking services. </p>
<p>All participants receive an identical type of behavioural support to stop smoking, based on the stop smoking services’ support framework. And we are still looking for people to take part in the study. Participants must be willing to give up smoking and be prepared to follow their assigned programme. </p>
<h2>Quitting for good</h2>
<p>The research team is measuring participants’ cholesterol levels and their nicotine dependence. We are also looking at the amount of carbon monoxide in their breath and assessing the functioning of the small arteries and veins. Results of this mini “check-up” are provided to participants as well.</p>
<p>Preliminary findings show that people who are randomly allocated to the e-cigarette groups are most likely not to take up smoking again and complete their stop smoking attempt, within the study course. </p>
<p>This supports <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010216.pub3/full">previous work</a> and anecdotal evidence in the field – but to make sure this is definitely the case, we are also dividing participants in each group between those who are successful and those who are not. We are assessing the reasons why the latter group didn’t complete their attempt. </p>
<p>It is hoped that in time, these findings will help to inform new guidelines around the use of e-cigarettes to quit smoking. Importantly, this work will also allow smokers to be given more options and be better informed, so that they can stop smoking for good.</p>
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<p><em>If you are interested in taking part in the study, contact the research team at 0114 2254312 or email: heartresearch@shu.ac.uk</em></p><img src="https://counter.theconversation.com/content/109098/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Markos Klonizakis receives funding from Heart Research UK (RG2658) for his work on the study of the physiological effects of e-cigarettes on small veins and arteries.</span></em></p>E-cigarettes may help smokers quit but research is still limited.Markos Klonizakis, Reader (Clinical Physiology), Sheffield Hallam UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/973822018-05-31T12:05:04Z2018-05-31T12:05:04ZHow South Africa is tightening its tobacco rules<figure><img src="https://images.theconversation.com/files/221132/original/file-20180531-69481-i0m72z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">South Africa was a leader in tobacco control but has not updated its policies adequately.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>South Africa’s Health Minister Aaron Motsoaledi has published a <a href="https://www.gov.za/document/latest">new tobacco control bill</a> which, if passed into law, will tighten the grip on how cigarettes and other tobacco products are sold, marketed and regulated in the country. Health and Medicine Editor Candice Bailey asked Catherine Egbe about what it means for tobacco control.</em></p>
<p><strong>What’s significant about South Africa’s pending tobacco control legislation?</strong></p>
<p>There are five key areas of tobacco control that the new bill seeks to address: </p>
<ul>
<li><p>a smoke-free policy, </p></li>
<li><p>plain or standardised cigarette packaging, </p></li>
<li><p>regulating e-cigarettes, </p></li>
<li><p>points of sale marketing, and </p></li>
<li><p>removing cigarette vending machines. </p></li>
</ul>
<p>Some are addressed in South Africa’s current tobacco control law. But the country still doesn’t fully comply with the standards set by the World Health Organisation’s <a href="http://www.who.int/fctc/text_download/en/">Framework Convention on Tobacco Control</a>. South Africa signed the convention in 2005.</p>
<p>Smoke-free public places is one example. The current law bans smoking in public places but allows for designated smoking areas in places like bars, taverns and restaurants provided that they do not take up more than 25% of the venue. </p>
<p>The WHO’s convention calls for 100% smoke-free public places to protect non-smokers fully.</p>
<p>In line with this, the new bill calls for a 100% ban on smoking in public places. It will also ban the advertising of cigarettes and other products at tills or selling them in vending machines. </p>
<p>The health warnings on cigarette boxes and other tobacco product packages is another example. The current law allows for text health warning on 20% of the package. But the convention calls for a minimum of 30% and encourages countries to have the more effective plain or standardised packaging with graphic and textual warnings in place. </p>
<p>So the new law mandates standardised packaging with graphic health warnings to make tobacco packages less attractive to new smokers and to discourage old smokers from continuing to smoke.</p>
<p>The bill is also significant because it attempts to regulate e-cigarettes for the first time in South Africa. To date e-cigarettes have been freely marketed and sold anywhere to anyone, including children. </p>
<p><strong>Is there evidence that the planned interventions will work?</strong></p>
<p>There’s a great deal of evidence from the rest of the world.</p>
<p>Let’s start with smoke-free policies. In countries like South Korea and the US where they are in place, research shows that they led to an overall <a href="http://www.jksrnt.org/journal/view.html?uid=93&&vmd=Full">improvement in health</a>, particularly <a href="https://ac.els-cdn.com/S0140673614600829/1-s2.0-S0140673614600829-main.pdf?_tid=9f329e15-83a6-4326-be76-3df681abc165&acdnat=1527684144_394c509d8bb6a67ff3cca6b8a42f9026">children’s</a> health. </p>
<p>Incidents of <a href="https://www.ncbi.nlm.nih.gov/pubmed/29775915">smoking-related cancers</a> went down and there was a reduction in <a href="http://bmjopen.bmj.com/content/8/3/e022490">childhood smoking</a>. There was also an increase in the number of smokers saying they want to <a href="https://www.hindawi.com/journals/bmri/2015/853418/">quit</a>.</p>
<p>When it comes to packaging, studies show that it <a href="http://www.tobaccopreventioncessation.com/Refuting-tobacco-industry-funded-research-empirical-data-shows-decline-in-smoking-prevalence-following-introduction-of-plain-packaging-in-Australia,60650,0,2.html">encourages</a> smokers to <a href="https://www.mja.com.au/journal/2014/200/1/association-between-tobacco-plain-packaging-and-quitline-calls-population-based">quit</a> and <a href="https://ijbnpa.biomedcentral.com/articles/10.1186/s12966-016-0421-7">discourages young people</a> from wanting to start smoking. Plain packaging was first introduced in Australia in 2012. </p>
<p>E-cigarettes are still a relatively new factor. But research is already casting doubts on various claims made about them. First introduced in <a href="http://articles.latimes.com/2009/apr/25/world/fg-china-cigarettes25">China in 2004</a> they were initially mooted as an aid to quit smoking. But research shows that they in fact encourage young people to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5938547/">start smoking cigarettes</a>. And 18 studies have shown that e-cigarettes do not reduce quit rates. Instead, the <a href="https://www.ncbi.nlm.nih.gov/pubmed/29582077">latest research</a> shows that they do the reverse – they reduce the quit rates of smokers intending to quit by about 66%.</p>
<p>There are <a href="https://globaltobaccocontrol.org/node/14052">83 countries</a> that regulate e-cigarettes and about <a href="https://globaltobaccocontrol.org/e-cigarette/policy-domains">27</a> that have completely banned their sale. These include Brazil, Singapore, Uruguay, Seychelles and Uganda. </p>
<p>The advertising, promotion and sponsorship of e-cigarettes are regulated or prohibited in <a href="https://globaltobaccocontrol.org/e-cigarette/policy-domains">62 countries</a>. </p>
<p><strong>Why is it important to have a legislation like this?</strong></p>
<p>Tobacco smoking is the single most preventable cause of death in the world. Smoking also <a href="https://www.cdc.gov/globalaids/success-stories/perfectstorm.html">worsens TB and HIV treatment outcomes</a>. Yet 37% of South African men and 6.8% of South African women aged 15 years and <a href="http://www.mrc.ac.za/sites/default/files/files/2017-05-15/SADHS2016.pdf">older use tobacco </a>.</p>
<p>Before the WHO Framework Convention on Tobacco Control, South Africa was a leader in tobacco control in Africa and across the world because of strong tobacco control legislation it had put in place. But the laws weren’t updated according to current WHO’s standards and the country now lags behind some other African countries.</p>
<p>The new legislation will place South Africa on the right path. Apart from saving millions of lives, it will ensure that South Africa fulfils its obligation as a party to the WHO convention.</p>
<p>There are several benefits to having strong legislation. </p>
<p>Firstly, it will protect millions of South Africans who don’t smoke but take in secondhand smoke from those who do. They face the same <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/index.htm">health risks</a> as active smokers. </p>
<p>Secondly, it will also help encourage people to quit and live healthier lives and discourage young people from starting. </p>
<p>And thirdly, the tobacco industry views young people as <a href="http://www.who.int/tobacco/media/en/TobaccoExplained.pdf">replacement smokers</a>. Strong legislation will prevent young people from being manipulated by the tobacco industry.</p>
<p><strong>What are the next steps?</strong></p>
<p>Once the bill becomes law, the health minister will have to draw up several regulations to guide its implementation. These will ensure that the law is interpreted correctly and not manipulated by the tobacco industry and that the potential gains of the legislation are not watered down.</p><img src="https://counter.theconversation.com/content/97382/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine O. Egbe's works as a postdoctoral research fellow at the UCSF Center for Tobacco Control Research and Education (2015 - 2017) were previously funded by the National Cancer Institute Grant CA-087472. </span></em></p>South Africa’s proposed new tobacco laws will tighten the grip on how cigarettes and other tobacco products are sold, marketed and regulated in the country.Catherine O. Egbe, PhD, Specialist Scientist, Alcohol Tobacco and Other Drug Research Unit, South African Medical Research CouncilLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/822412017-08-21T10:54:12Z2017-08-21T10:54:12ZWhy lowering nicotine in cigarettes could change the course of health<figure><img src="https://images.theconversation.com/files/182620/original/file-20170818-7949-6sk4rf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Studies have shown that most smokers wish they had never smoked and that they wish they could stop. Lowering the levels of nicotine, the addictive chemical in cigarettes, would be a big step. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/nicotine-dangerous-life-vintage-burnt-paper-678117133?src=RoCjlelrfEbq96ShH8UWpA-1-16">DenisProductions.com/Shutterstock.com</a></span></figcaption></figure><p>The new commissioner of the Food and Drug Administration (FDA) recently made a <a href="https://www.washingtonpost.com/news/to-your-health/wp/2017/07/28/fda-delay-e-cigarette-rules-years-explore-reducing-nicotine-conventional-cigarettes/?utm_term=.da1049189ba3">surprising and bold announcement</a> that could potentially save more lives than if we ended the opioid epidemic today. FDA Commissioner Scott Gottlieb, a physician and cancer survivor, said that federal regulators will start a conversation about dramatically reducing the amount of nicotine in cigarettes, low enough to make them nonaddictive, while taking a go-slow approach to adopting new regulations on electronic cigarettes and other devices that are increasingly popular for consuming nicotine.</p>
<p><a href="https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm568923.htm">As Gottlieb put it</a>, efforts to reduce smoking in the United States call for “Envisioning a world where cigarettes would no longer create or sustain addiction, and where adults who still need or want nicotine could get it from alternative and less harmful sources.”</p>
<p>This is a potentially historic announcement that offers a common-sense approach to moving the nation forward in our effort to reduce the number of illnesses and deaths caused by smoking. It is certainly an approach that has scientific merit.</p>
<p>I have spent decades working to reduce the harm of tobacco use. In 1992, I joined the Centers for Disease Control and Prevention as director of the Office on Smoking and Health. I can recall when the FDA’s standard response to requests that it regulate nicotine in cigarettes was to assert that cigarettes are neither a food nor a drug, but “a device of pleasure” outside of their authority.</p>
<p>I can assure you that few smokers derive true pleasure from their addiction. My research team has found that <a href="https://www.ncbi.nlm.nih.gov/pubmed/28383508">most smokers regret that they ever started</a>, and they desperately want to quit the habit. </p>
<h2>The death toll of smoking: 15 times higher than for opioids</h2>
<p>Though the opioid crisis is currently attracting the attention of the media and decision-makers across society, <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm">smoking remains the leading cause of preventable death and disease</a> in the United States, causing more than 480,000 deaths a year. To put the scourge of conventional cigarettes in context, <a href="https://www.vox.com/science-and-health/2017/8/1/16069684/fda-tobacco-regulation-nicotine-cigarette-smoking-deaths">smoking kills 15 times more Americans</a> per year than opioids.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/182621/original/file-20170818-7944-1ceq5w1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/182621/original/file-20170818-7944-1ceq5w1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=453&fit=crop&dpr=1 600w, https://images.theconversation.com/files/182621/original/file-20170818-7944-1ceq5w1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=453&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/182621/original/file-20170818-7944-1ceq5w1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=453&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/182621/original/file-20170818-7944-1ceq5w1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=569&fit=crop&dpr=1 754w, https://images.theconversation.com/files/182621/original/file-20170818-7944-1ceq5w1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=569&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/182621/original/file-20170818-7944-1ceq5w1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=569&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Smoking is the number one risk factor for lung cancer, but it also harms our lungs in other ways. In addition, smoking has been linked to 30 types of cancer and heart disease.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/lungs-234361483?src=ij2Pj5KHHPBk_GUtt-Ty1w-1-77">sciencepics/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Most Americans understand that smoking can cause cancer, but they may not be aware that it is also tied to a wide range of other health problems including heart disease, stroke and chronic obstructive pulmonary disease. In fact, <a href="http://content.healthaffairs.org/content/36/8/1423.abstract">a new study published in the journal Health Affairs</a> found that infant mortality across the 13-state Appalachia region was 16 percent higher than the rest of the U.S. and overall life expectancy 2.4 years shorter, largely due to the higher rates of smoking in Appalachia.</p>
<p>As Gottlieb has noted, cigarettes are the only legal consumer product that, when used as intended, <a href="https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm568923.htm">will kill half of all long-term users</a>.</p>
<p>The new approach that Gottlieb proposes is a first step on a long journey that has great promise. If nicotine levels in cigarettes can be reduced significantly, it won’t take long for smokers to realize that lighting up more frequently and dragging more deeply will never give them the same nicotine hit as in the past. This novel and intriguing idea is that smokers would quickly switch to e-cigarettes or other alternatives to get the nicotine they seek, a much <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1707409#t=article">safer option than burning tobacco</a> and inhaling the smoke. Of course, regulators would have to figure out how to prevent black market sales of high-nicotine cigarettes.</p>
<p>Meanwhile, low-nicotine cigarettes would be less likely to hook a new generation of young smokers. Nearly <a href="https://www.tobaccofreekids.org/research/factsheets/pdf/0127.pdf">90 percent of adult smokers took up the habit</a> before they turned 18. Making cigarettes less appealing and addictive to young people would be revolutionary and would put the goal of a smoke-free generation within grasp.</p>
<h2>An opening to e-cigarettes?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/182624/original/file-20170818-7959-1nxlmie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/182624/original/file-20170818-7959-1nxlmie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/182624/original/file-20170818-7959-1nxlmie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/182624/original/file-20170818-7959-1nxlmie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/182624/original/file-20170818-7959-1nxlmie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/182624/original/file-20170818-7959-1nxlmie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/182624/original/file-20170818-7959-1nxlmie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Critics of Scott Gottlieb’s announcement on lowering nicotine in cigarettes fear that a side component of his plan will encourage more e-cigarettes, which many health experts see as a gateway to cigarettes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/closeup-man-vaping-electronic-cigarette-390689176?src=XNbURhYklTXj5zL2Nb3tvA-1-12">Oleg GawriloFF/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Some critics have focused on Gottlieb’s <a href="https://www.washingtonpost.com/news/to-your-health/wp/2017/07/28/fda-delay-e-cigarette-rules-years-explore-reducing-nicotine-conventional-cigarettes/?utm_term=.da1049189ba3">decision to delay the regulatory process for e-cigarettes</a>, hookahs and other novel products while exploring how to reduce nicotine in traditional cigarettes. But he has pledged not to delay important, common-sense regulations to protect children from accidental poisoning by making the containers of liquid nicotine for e-cigarettes child-proof, and by setting standards for battery packs which occasionally burn or explode, injuring users.</p>
<p>The public will need to be patient because the regulatory process is extraordinarily slow. In fact, the first step is the arcane-sounding “Advance notice of proposed rule-making,” and there are <a href="https://www.reginfo.gov/public/reginfo/Regmap/index.jsp">nine steps</a> in all to adopting a new regulation.</p>
<p>It’s also unclear whether <a href="https://www.bloomberg.com/news/articles/2017-08-03/big-tobacco-won-t-let-the-fda-cut-nicotine-without-a-fight">tobacco companies will fight the FDA’s proposal</a> to reduce nicotine in conventional cigarettes by dragging the debate through the court system. In the past, cigarette makers have been quick to file lawsuits or mount lobbying campaigns to head off perceived threats to their industry. Right now, an organization receiving substantial financial support from R.J. Reynolds Tobacco Co. is <a href="http://www.sfchronicle.com/bayarea/article/SF-ban-on-flavored-tobacco-looks-headed-for-the-11408689.php">pushing for a repeal</a> of a decision by San Francisco city leaders to ban the sale of flavored tobacco products, which are widely seen as appealing to young people. Indeed, <a href="http://money.cnn.com/2017/07/28/investing/tobacco-stocks-altria-fda-cigarettes-nicotine/index.html">stock prices for the big cigarette producers</a> plunged after the FDA announcement, a signal that the FDA proposal was seen as bad for their bottom line.</p>
<p>However, it’s worth noting that several cigarette manufacturers are also entering the <a href="https://blogs.wsj.com/corporate-intelligence/2013/11/18/big-tobacco-begins-its-takeover-of-the-e-cigarette-market/">market for e-cigarettes and other novel nicotine delivery devices</a>, so they may be ready to switch rather than fight (to reverse a line from an <a href="https://www.youtube.com/watch?v=RB6C3o_-RdE">old tobacco ad</a>). For a sense of how the strategy, or at least the public messaging, of some cigarette makers is evolving, go to the homepage of tobacco giant <a href="https://www.pmi.com/">Philip Morris International</a>, where the splashy design claims the company is “Designing a Smoke-Free Future.”</p>
<p>There are many forces at work, but the good news is that scientists and the general public will get opportunities to offer their input as this process moves forward. And a growing number of state and local governments are adopting their own policies to protect young people from smoking cigarettes, including <a href="https://www.vox.com/policy-and-politics/2017/8/10/16125890/oregon-smoking-age-21">raising the legal age</a> to purchase tobacco products from 18 to 21.</p>
<p>In the meantime, I want to encourage smokers to do what they can to quit. Don’t get discouraged and don’t put it off. Most people make several “failed” attempts to quit before they manage to quit for good.</p>
<p><a href="https://smokefree.gov/">Find the method that works for you</a>, and if it’s e-cigarettes, make sure you really are using them to help you quit smoking conventional cigarettes and not falling into the trap of becoming a “dual user” who never kicks the smoking habit. Stay focused on the goal – to stop inhaling the toxic smoke that’s generated by setting tobacco on fire.</p><img src="https://counter.theconversation.com/content/82241/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael P. Eriksen receives funding from Pfizer, Inc for tobacco control work in China. He is also the Principal Investigator on the Georgia State University Tobacco Center of Regulatory Science (grant number P50DA036128 from the National Institute on Drug Abuse and FDA Center for Tobacco Products). The content is solely the responsibility of Dr. Eriksen and does not necessarily represent the official views of the NIH or the Food and Drug Administration.</span></em></p>FDA Director Scott Gottlieb has proposed discussions about drastically cutting nicotine levels in cigarettes. This could result in some of the biggest health gains in history.Michael P. Eriksen, Professor and Dean, School of Public Health, Georgia State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/684282016-11-30T19:18:29Z2016-11-30T19:18:29ZHow e-cigarettes could ‘health wash’ the tobacco industry<figure><img src="https://images.theconversation.com/files/146181/original/image-20161116-13555-1ac2es0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Classifying e-cigarettes as a nicotine replacement therapy could help the tobacco industry influence health policy.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/237371161?src=sql-LWcr4laxp9REXUUEgA-1-22&id=237371161&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>The evidence that e-cigarettes help people quit smoking was described in the World Health Organisation’s (WHO) recent <a href="http://www.who.int/fctc/cop/cop7/FCTC_COP_7_11_EN.pdf">report</a> as “scant and of low certainty”. Predictably, this triggered the latest <a href="https://www.theguardian.com/society/2016/nov/04/vaping-does-not-help-people-stop-smoking-says-who-report">round</a> of claims and counterclaims in an ongoing, and often acrimonious, dispute about the potential of e-cigarettes.</p>
<p>This lack of definitive evidence about either their efficacy or their long term health effects, outlined by the WHO, is echoed by <a href="http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(15)00521-4/abstract">others</a>, including Australia’s <a href="https://www.nhmrc.gov.au/guidelines-publications/ds13">National Health and Medical Research Council</a>.</p>
<p>Regulatory authorities outside Australia have classified e-cigarettes as medical devices or smoking cessation aids, similar to nicotine replacement therapy, like patches or gums. So far tobacco companies are the only actors to successfully gain medical licences for such products, although none have yet come to market.</p>
<p>But the decision to seek medical approval for their products may have serious consequences.</p>
<p>It may allow the industry to reclaim a role in health policy, part of a wider strategy by tobacco companies to rebrand themselves as nicotine companies with a key role in the fight against smoking.</p>
<p>By positioning themselves as “part of the solution”, rather than the essence of the problem, the tobacco industry is seeking to claw back from its pariah status and to re-engage in the policy process.</p>
<p>Policy makers who would shun overtures from Big Tobacco may nonetheless be prepared to meet with “nicotine companies” and producers of smoking cessation devices. This offers tobacco companies a significant opportunity to shape regulatory debates surrounding their core cigarette businesses, potentially undermining effective tobacco control policies which have driven declining smoking rates in Australia and elsewhere.</p>
<h2>How are e-cigarettes regulated?</h2>
<p>The lack of definitive evidence about either e-cigarettes’ efficacy or long term health effects underlies the Australian government’s decision to implement a near-complete ban.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/145692/original/image-20161114-9081-8kyo63.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/145692/original/image-20161114-9081-8kyo63.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=776&fit=crop&dpr=1 600w, https://images.theconversation.com/files/145692/original/image-20161114-9081-8kyo63.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=776&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/145692/original/image-20161114-9081-8kyo63.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=776&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/145692/original/image-20161114-9081-8kyo63.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=975&fit=crop&dpr=1 754w, https://images.theconversation.com/files/145692/original/image-20161114-9081-8kyo63.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=975&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/145692/original/image-20161114-9081-8kyo63.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=975&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">E-cigarette shop, Paris (supplied).</span>
</figcaption>
</figure>
<p>Current <a href="http://www.racgp.org.au/afp/2015/june/e-cigarettes-and-the-law-in-australia/">regulations</a> prohibit the sale, supply and possession of e-cigarettes containing nicotine. Regulation of the use of e-cigarettes in public places, their marketing and promotion varies by state, adding a further level of legal uncertainty.</p>
<p>People can import e-cigarettes as an unapproved therapeutic good with a prescription. However, most vapers (e-cigarette users), are unlikely to visit doctors to access products readily available over the internet. Many vapers also reject the idea they are sick and need to be cured.</p>
<p>Australia’s position differs from that of other jurisdictions. The European Union, for example, allows e-cigarettes to be sold as licensed medical devices or as non-medical products if they meet certain criteria set out in the 2014 <a href="http://ec.europa.eu/health/tobacco/products/revision/index_en.htm">Tobacco Products Directive</a>.</p>
<p>In the UK, British American Tobacco is the only company so far to have obtained a medical licence for an electronic nicotine delivery device, although its Voke brand is not yet on the market. This opens the possibility that UK patients could be prescribed tobacco industry products on the National Health Service.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/145689/original/image-20161114-9077-f8nh9u.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/145689/original/image-20161114-9077-f8nh9u.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=660&fit=crop&dpr=1 600w, https://images.theconversation.com/files/145689/original/image-20161114-9077-f8nh9u.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=660&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/145689/original/image-20161114-9077-f8nh9u.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=660&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/145689/original/image-20161114-9077-f8nh9u.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=829&fit=crop&dpr=1 754w, https://images.theconversation.com/files/145689/original/image-20161114-9077-f8nh9u.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=829&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/145689/original/image-20161114-9077-f8nh9u.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=829&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Vype advert, UK (supplied).</span>
</figcaption>
</figure>
<p>In 2013, British American Tobacco subsidiary Nicovations applied to the Australian Therapeutic Goods Administration (TGA) to have Voke licensed as part of its “<a href="http://www.abc.net.au/news/2014-10-02/tobacco-giant-wants-e-cigarettes-classed-as-medicine/5786508">medicines-based approach</a>” to reduce the harms from smoking. When the TGA refused to evaluate its application, Nicovations successfully took the issue to the <a href="http://www.judgments.fedcourt.gov.au/judgments/Judgments/fca/single/2016/2016fca0394">Federal Court</a>, which in April 2016 <a href="http://www.smh.com.au/federal-politics/political-news/federal-court-forces-drug-regulator-to-consider-nicotine-inhaler-case-20160421-goc3kx.html">ruled</a> the TGA was required to consider the company’s submission.</p>
<p>Another British American Tobacco brand, Vype, which is not regulated as a medical device, is sold in UK pharmacies alongside nicotine replacement products. It is being positioned – both physically and symbolically – as a smoking cessation tool.</p>
<h2>Do we need products to help us stop smoking?</h2>
<p>Current debates on e-cigarettes occur in a context in which quitting smoking has become defined as a treatable medical condition and the best way to stop smoking is to buy a manufactured remedy. This situation is the result of aggressive promotion by pharmaceutical companies that manufacture nicotine replacement therapies and other pharmacotherapy. </p>
<p>Despite the <a href="http://jamanetwork.com/journals/jama/article-abstract/1812969">reality</a> that the overwhelming majority of ex-smokers quit without using pharmaceutical products, the manufacturers of nicotine replacement therapy have successfully shaped perceptions around how smokers quit, both in Australia and internationally.</p>
<p>Tobacco companies’ investment in e-cigarettes builds on the medicalisation of smoking cessation. While some companies have invested in developing medical devices, the vast majority of tobacco companies’ “next generation” products, including e-cigarettes, are carefully differentiated from existing nicotine replacement therapies. They are positioned as smoking substitutes rather than overtly medical treatments. </p>
<p>Indeed, the development of medical products may be intended to draw attention to the availability of non-medical substitutes, which are targeted at smokers who do not see themselves as unwell or in need of treatment but may be attracted by substitute products.</p>
<p>Niconovum USA, Inc, a subsidiary of Reynolds American, provides a particularly explicit example through production of Zonnic nicotine gum and other products. As Niconovum’s president <a href="http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2016.303456">said</a> recently:</p>
<blockquote>
<p>Many smokers do not see smoking as a medical condition and, thus, have not been reached by traditional nicotine replacement therapy marketing and channels of distribution.</p>
</blockquote>
<p>The current developments in smoking cessation and the evolving corporate strategy of Big Tobacco means we need to be clear about the key issues and participants in current smoking cessation debates. </p>
<p>The marketing of e-cigarettes as smoking cessation products will reinforce misconceptions among policy makers and the wider public that some form of medical or non-medical replacement product is required to quit smoking. It will also reinforce the idea that to drive quit rates, it is both necessary and legitimate to engage with the producers of these products.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/145694/original/image-20161114-9048-1ebr979.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/145694/original/image-20161114-9048-1ebr979.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=799&fit=crop&dpr=1 600w, https://images.theconversation.com/files/145694/original/image-20161114-9048-1ebr979.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=799&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/145694/original/image-20161114-9048-1ebr979.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=799&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/145694/original/image-20161114-9048-1ebr979.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1004&fit=crop&dpr=1 754w, https://images.theconversation.com/files/145694/original/image-20161114-9048-1ebr979.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1004&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/145694/original/image-20161114-9048-1ebr979.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1004&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Smoking cessation products display, UK (suppplied).</span>
</figcaption>
</figure>
<p>Investment by tobacco companies in e-cigarettes raises important concerns regarding the renormalisation of the industry, and the impact on tobacco control policies. It, may, for instance, allow tobacco companies to reposition themselves as key partners in the health policy process in ways <a href="https://responsibilitydeal.dh.gov.uk/">similar</a> to the alcohol and food industries.</p>
<p>While meetings between governments and the tobacco industry are precluded by <a href="http://www.who.int/tobacco/wntd/2012/article_5_3_fctc/en/">Article 5.3</a> of the <a href="http://www.who.int/fctc/text_download/en/">Framework Convention on Tobacco Control</a>, tobacco companies will be able to argue such restrictions do not extend to their e-cigarette subsidiaries. </p>
<p>Despite strategies to rebrand themselves as nicotine companies and technological innovators, the core business of the tobacco industry, and its sources of profit, remains firmly focused on conventional tobacco products.</p>
<p>As such, governments should approach e-cigarettes and their producers with caution. Tobacco companies, including their subsidiaries, must be viewed as tobacco companies in all contexts, and governments should adhere to internationally accepted norms of non-engagement.</p><img src="https://counter.theconversation.com/content/68428/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ross MacKenzie receives funding from the National Institutes of Health. He he has previously worked on research projects funded by the Rockefeller Foundation, and Cancer Council NSW.</span></em></p><p class="fine-print"><em><span>Benjamin Hawkins receives funding from the US National Institute of Health (Grant No. R01-CA091021).</span></em></p>Classing e-cigarettes as quit smoking aids could help rebrand the tobacco industry as a legitimate player in health policy. Here’s why we should be concerned.Ross MacKenzie, Lecturer in Health Studies, Macquarie UniversityBenjamin Hawkins, Lecturer in Global Health Policy, London School of Hygiene & Tropical MedicineLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/587252016-05-02T04:25:34Z2016-05-02T04:25:34ZAustralia’s prohibition of e-cigarettes is out of step with the evidence<figure><img src="https://images.theconversation.com/files/120810/original/image-20160502-28155-vhf1q8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A Royal College of Physicians report has encouraged smokers to take up e-cigarettes.</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p><a href="https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0">A new report</a> by the Royal College of Physicians in the United Kingdom says electronic cigarettes (e-cigarettes) are much safer than smoking and encourages their widespread use by smokers. It concludes that e-cigarettes have huge potential to prevent death and disease from tobacco use.</p>
<p>The review identifies e-cigarettes as a valuable tool to help smokers quit. For those who are unable to quit with currently available methods, e-cigarettes can substitute for smoking by providing the nicotine to which smokers are addicted without the smoke that causes almost all of the harm. This approach is supported by the <a href="https://www.gov.uk/government/news/e-cigarettes-an-emerging-public-health-consensus">scientific and public health community in the UK</a> and is consistent with a previous <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457102/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf">review by Public Health England</a>, the government health agency.</p>
<p>E-cigarettes are <a href="http://www.smokinginengland.info/downloadfile/?type=latest-stats&src=11">the most commonly used aid to quit smoking</a> in the UK. According to the new review, evidence available so far suggests e-cigarettes are at least as effective as nicotine replacement therapy, such as patches or chewing gum. <a href="http://www.ash.org.uk/files/documents/ASH_891.pdf">More than one million people</a> have quit smoking in the UK using e-cigarettes. Quit rates are likely to be even higher with professional counselling and with more advanced devices.</p>
<p>E-cigarettes have been available in the UK since 2007 as a general consumer product – with some additional restrictions on advertising and minimum age of sale. They’re used <a href="https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0">almost exclusively</a> in the UK by smokers who are trying to cut down or quit smoking, or who have quit smoking.</p>
<h2>Concerns about e-cigarettes</h2>
<p>In Australia, e-cigarettes containing nicotine are <a href="https://www.tga.gov.au/community-qa/electronic-cigarettes">prohibited</a>. Most Australian health organisations such as the <a href="http://wiki.cancer.org.au/policy/Position_statement_-_Electronic_cigarettes">National Heart Foundation, Cancer Council Australia</a> and the <a href="https://ama.com.au/position-statement/tobacco-smoking-and-e-cigarettes-2015">Australian Medical Association</a> take a very risk-averse approach based on potential harms. They say e-cigarettes could be a gateway to smoking for non-smokers; they may make the act of smoking socially acceptable again (renormalisation); there may be unknown long-term safety risks; and dual use may delay quitting.</p>
<p>The new review explores the evidence for these concerns and says they are mostly unfounded.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/120811/original/image-20160502-28136-1rfhmtv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/120811/original/image-20160502-28136-1rfhmtv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/120811/original/image-20160502-28136-1rfhmtv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/120811/original/image-20160502-28136-1rfhmtv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/120811/original/image-20160502-28136-1rfhmtv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/120811/original/image-20160502-28136-1rfhmtv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/120811/original/image-20160502-28136-1rfhmtv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/120811/original/image-20160502-28136-1rfhmtv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Concerns e-cigarettes could be a gateway to smoking are not backed by evidence.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<p>In the UK, there is no evidence e-cigarettes are a gateway to smoking. E-cigarette use is almost entirely restricted to current or past smokers. Use by children who would not otherwise have smoked appears to be minimal.</p>
<p>The report found no evidence to suspect the use of e-cigarettes renormalises smoking. On the contrary, smoking rates in the UK have been falling as e-cigarette use rises.</p>
<p>E-cigarette vapour contains some toxins and the report acknowledges some harm from long-term use cannot be dismissed. However, it supports the widely held view that the hazard to health is unlikely to exceed 5% of the risk of smoking, and may well be substantially lower. This level of harm is similar to nicotine replacement therapy and is likely to reduce with further technological advances. Similarly, the report concludes the harm to bystanders from vapour exposure is negligible.</p>
<p>Many e-cigarette users continue to smoke as well for a period of time (dual use) but there is no evidence this has reduced the number of smokers who quit. Indeed, dual use is often a transitional phase and many users will go on to quit completely as is the case of smokers concurrently using nicotine replacement therapy. A <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=26333731">recent study</a> found dual use reduces smoking intake and is less hazardous.</p>
<h2>Implications for Australia</h2>
<p>Australia has a comprehensive tobacco control policy including high tobacco taxes, mass media campaigns and smoke-free policies that stimulate quit attempts. However, smoking is highly addictive and most of Australia’s three million smokers try and fail repeatedly to quit, even with existing therapies</p>
<p>Based on the UK experience, e-cigarettes <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4171752/pdf/add0109-1531.pdf">could assist many Australian smokers</a> to quit or could replace cigarettes with a much safer source of nicotine. This could potentially save many thousands of lives each year.</p>
<p>As established smokers are more likely to be socioeconomically disadvantaged or to have mental health problems, the burden of disease falls disproportionately on these groups who have higher levels of addiction to nicotine and greater difficulty quitting.</p>
<p>The precautionary position taken by Australian health organisations and governments is not supported by the available evidence and overseas experience. The growing evidence for safety and effectiveness of e-cigarettes significantly outweighs any potential risks to public health.</p>
<p>A rational, evidence-based approach would be to make e-cigarettes available in Australia as consumer products and to encourage their use while minimising uptake by people who would not otherwise have used nicotine products. Ongoing monitoring and appropriate proportionate regulation would help minimise any risks.</p>
<p>E-cigarettes represent a massive opportunity for Australian smokers and have the potential for large-scale improvements in individual and public health, and social inequality. We cannot afford not to embrace them.</p><img src="https://counter.theconversation.com/content/58725/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Colin Mendelsohn receives funding from Pfizer Australia, GlaxoSmithKline and Johnson & Johnson Pacific for teaching, consulting and conference expenses.</span></em></p>A new report has found electronic cigarettes (e-cigarettes) are much safer than smoking and has encouraged their widespread use among smokers.Colin Mendelsohn, Casual Lecturer, Smoking Cessation and Nicotine Dependence and Tobacco Treatment Specialist, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/531532016-01-14T17:54:16Z2016-01-14T17:54:16ZHow shaky are the twin pillars of the case for e-cigarettes?<figure><img src="https://images.theconversation.com/files/108109/original/image-20160114-10402-rj4k6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The odds of quitting cigarettes are 28% lower in those who use e-cigarettes compared with those who don't.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-189413459/stock-photo-closeup-of-man-using-e-cigarette-and-exhaling-vapor-shot-over-black-background.html?src=TH5xj1tLIts2R1VrmyVdtA-1-31">pryzmat/Shutterstock</a></span></figcaption></figure><p>The central arguments made for the importance of electronic cigarettes (e-cigarettes) are that they are an exceptionally good way to quit smoking and that they represent trivial risk to health compared to the stratospheric risks of smoking. (<a href="https://theconversation.com/smoking-new-australian-data-to-die-or-live-for-37962">Australian data</a> published last year from the very large 45 and Up cohort study found that up to two in three long-term smokers were likely to die from a smoking-caused disease.)</p>
<p>Two just-released papers promise to further ignite debate about these two central pillars of the case being made for these putative harm-reduction products.</p>
<p>A systematic review of all studies examining whether smokers who use e-cigarettes quit smoking at a different rate to those who don’t has been published today in <a href="http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(15)00521-4/abstract">Lancet Respiratory Medicine</a>. The review identified 38 studies, with 20 having control groups. </p>
<p>Pooling these, they found that the odds of quitting cigarettes were 28% lower in those who used e-cigarettes compared with those who didn’t.</p>
<p>Of course, not all vapers are using e-cigarettes to quit. Many use them to just cut down, often in the erroneous belief that reducing the number of cigarettes smoked daily will reduce harm. I summarised and linked to four cohort studies that demonstrate this folly in a recent lengthy <a href="https://theconversation.com/spotless-leopards-decoding-hype-on-e-cigarettes-49291">Conversation</a> piece.</p>
<p>So if many smokers are not even trying to quit with e-cigs, some might argue that that there should be no expectation that they would. </p>
<p>The problem with that assumption is that we have an increasing understanding that many smokers do not plan to try to quit, but rather do it quite spontaneously. </p>
<p>For example, in this <a href="http://www.bmj.com/content/bmj/332/7539/458.full.pdf">2006 paper</a> on a national sample of English smokers, 48.6% of smokers reported that:</p>
<blockquote>
<p>their most recent quit attempt was put into effect immediately the decision to quit was made. Unplanned quit attempts were more likely to succeed for at least six months: among respondents who had made a quit attempt between six months and five years previously the odds of success were 2.6 times higher (95% confidence interval 1.9 to 3.6) in unplanned attempts than in planned attempts.</p>
</blockquote>
<p>In this new review, the authors consider both smokers who were trying to quit by using e-cigs and those who were not. They found that:</p>
<blockquote>
<p>the association of e-cigarette use with quitting did not significantly differ among studies of all smokers using e-cigarettes (irrespective of interest in quitting cigarettes) compared with studies of only smokers interested in cigarette cessation.</p>
</blockquote>
<p>In other words, regardless of whether a smoker using e-cigarettes was planning to quit or not, there was no difference in whether they did.</p>
<p>The authors note that pooled estimates in previous reviews of e-cigarettes’ usefulness in smoking cessation did not include a comparison to other means of stopping besides e-cigarette use, so they cannot be used to determine whether e-cigarettes are associated with greater cigarette abstinence than quit rates being obtained in current practice.</p>
<p>They speculate that the poorer performance of e-cigs across all studies when pooled may mirror the changing situation of nicotine replacement therapy:</p>
<blockquote>
<p>Data from the large population-based California Tobacco Surveys, showed that nicotine replacement therapy (NRT) was associated with long-term success in quitting cigarettes when available by prescription only, but this association was lost when NRT became available over-the-counter. </p>
</blockquote>
<p>This view should challenge those calling for the greatest possible ease of obtaining e-cigarettes.</p>
<p>In a second paper, <a href="https://www.bookdepository.com/New-Technologies-for-Toxicity-Testing/9781461430544">globally renowned toxicologists</a> Robert Combes and Michael Balls have written a critical <a href="https://www.researchgate.net/publication/289674033_On_the_Safety_of_E-cigarettes_I_can_resist_anything_except_temptation1">commentary</a> stimulated by the 2015 publication of <a href="https://www.gov.uk/government/news/e-cigarettes-around-95-less-harmful-than-tobacco-estimates-landmark-review">Public Health England’s</a> (PHE) report on e-cigarettes. </p>
<p>The PHE report has already attracted <a href="http://www.theguardian.com/society/2015/sep/15/experts-criticise-public-health-england-e-cigarettes-review">critical commentary</a> in both the Lancet and the BMJ about the provenance of a key and globally telegraphed statement in the report that e-cigarettes were about “95% less harmful” than cigarettes.</p>
<p>This figure was conjured as a “best estimate” by a <a href="http://www.bmj.com/content/351/bmj.h4863">heavily criticised</a> consensus meeting of 12 people. Six of these were subsequent signatories to the 53 signature <a href="https://nicotinepolicy.net/documents/letters/MargaretChan.pdf">letter</a> to Dr Margaret Chan at the World Health Organization calling for minimal regulation. Six had no research track record or experience in tobacco control whatsoever. Two had financial ties to the tobacco or e-cigarette industries (see <a href="http://www.sciencedirect.com/science/article/pii/S0306460313003729">here</a> and <a href="https://www.karger.com/Article/Pdf/360220">here</a>). There was no transparency about how this group had been selected and questions remain about the <a href="http://www.bmj.com/content/351/bmj.h5826">role of the tobacco industry in its funding</a>.</p>
<p>Combes and Balls describe a recommendation from the PHE report that e-cigarettes be made available to smokers through the UK’s National Health Service as:</p>
<blockquote>
<p>a classic example of the temptation of short-term gain irrespective of the possibility of long-term pain.</p>
</blockquote>
<p>Pulling no punches, they argue that “lack of safety data and the resulting inability to perform any sort of risk assessment of the type normally undertaken for consumer products” makes the PHE’s recommendation “in the light of current knowledge [about e-cigarette safety] a reckless and irresponsible suggestion.”</p>
<p>Their commentary details numerous examples of significant absences of potential safety concerns in the PHE report, which appear to have been bypassed in light of what they call a well-meaning but misguided effort to propose a quick fix. </p>
<p>It is a paper that should be read by anyone who believes that the science is already settled on e-cigarettes.</p>
<p>Many e-cigarettes advocates are utterly convinced that vaping is highly effective at getting people off smoking, and of negligible health risk. It would be wonderful if they were right on both counts. These two papers should serve as a major amber light to such unbridled enthusiasm.</p>
<p>The very latest update of the <a href="http://www.smokinginengland.info/latest-statistics/">Smoking in England</a> project provides data that show that 68.2% of people who vape in England still continue to smoke (dual use): </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"687472781949186048"}"></div></p>
<p>And very worryingly, the percentage of smokers in England making a quit attempt in the last year is at the lowest point since 2007:</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"687473709452365824"}"></div></p>
<p>As <a href="https://theconversation.com/why-e-cigarettes-could-be-holding-back-your-plans-to-quit-smoking-52889">these Conversation authors</a> discussed, vaping may be holding many smokers back from quitting. At the population level, such an effect needs to balanced against the impact e-cigarettes may be having cessation so that we get an understanding of the net costs and benefits of e-cigarettes.</p>
<p>Some vaping advocates valiantly insist that their mission of “saving a billion lives” this century from tobacco deaths is so important that e-cigarettes should be able to by-pass all of the regulatory oversights that sensibly apply to chemicals and pharmaceuticals everywhere but in chaotic nations where anything goes and where consumers are unprotected from exploitation by manufacturers making misleading claims for useless and often dangerous products.</p>
<p>No one heroically claiming an AIDS or cancer cure on the same level of flimsy evidence of safety and efficacy that Combes and Balls point to with the current evidence base would get even a toe in the door to be allowed to sell and advertise such products. </p>
<p>If e-cigarettes are as safe and effective as their enthusiasts claim for them, let us all see the high quality data. We all want that, surely?</p>
<p><strong><em>Editor’s note: please ensure your comments are <a href="https://theconversation.com/au/community-standards">courteous and on-topic</a>.</em></strong></p><img src="https://counter.theconversation.com/content/53153/count.gif" alt="The Conversation" width="1" height="1" />
The central arguments made for the importance of electronic cigarettes (e-cigarettes) are that they are an exceptionally good way to quit smoking and that they represent trivial risk to health compared…Simon Chapman, Emeritus Professor in Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/465092015-09-01T04:44:20Z2015-09-01T04:44:20ZE-cigarettes may help smokers cut back but that doesn’t mean they’re not toxic<figure><img src="https://images.theconversation.com/files/93434/original/image-20150831-25714-2e8slw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research suggests that e-cigarettes are 95% less harmful than ordinary cigarettes but are still toxic. </span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>A recent <a href="http://jama.jamanetwork.com/article.aspx?articleid=2428954">study</a> showing teenagers who use e-cigarettes are three times more likely to smoke normal cigarettes than those who don’t amplifies the South African government’s calls to regulate e-cigarettes. </p>
<p>The study highlights the potential harm of e-cigarettes - or electronic cigarettes. These are the battery powered, pen-shaped devices delivering nicotine in a vapour instead of smoke which have taken the world by storm. It is also in contrast with other research that suggested e-cigarettes can reduce the harm of smoking if an individual uses them as a substitute.</p>
<p>The study comes months after South African Health Minister Aaron Motsoaledi announced his intentions to regulate the use of e-cigarettes. </p>
<p>Globally, the regulation of e-cigarettes remains <a href="http://www.who.int/nmh/events/2014/backgrounder-e-cigarettes/en/">controversial</a>. While some countries such as Brazil, Singapore and Switzerland have banned it, others like France and Canada have regulated it as a tobacco product. Some countries have regulated them as medicines because they are devices that deliver nicotine. </p>
<p>In South Africa e-cigarettes that contain nicotine are currently regulated under the Medicines and Related Substances Act as a schedule three substance. This means they can only be prescribed by a doctor and only be sold at a pharmacy. </p>
<p>But given the availability of these products in non-pharmaceutical retail outlets across the country, the level of enforcement of the current regulation remains questionable.</p>
<p>There are just under 200 000 e-cigarette users in South Africa. E-cigarettes have become fashionable among the country’s young adults. Sold at kiosks in malls, they come in different flavours that make them attractive to the youth. Some are marketed as healthy ‘herbal’ flavours. These numbers are likely to rise unless action is taken by the government to further regulate the devices’ use. </p>
<h2>Weighing up the pros and the cons</h2>
<p><a href="http://circ.ahajournals.org/content/129/19/1972.short">Experts</a> estimate that e-cigarettes are 95% safer than traditional cigarette smoking.
They have significantly <a href="http://tobaccocontrol.bmj.com/content/23/2/133.short">reduced toxicant</a> levels. This means they could potentially reduce the harm that comes with smoking combustible tobacco products such as cigarettes. This could help some smokers to quit. But others who cannot or do not want to stop smoking could switch to e-cigarettes to reduce smoking-related diseases and death. </p>
<p>In South Africa, smoking causes about <a href="http://www.samj.org.za/index.php/samj/article/view/661/156">45000 deaths</a> annually.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/92752/original/image-20150822-31376-1jl0ge0.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/92752/original/image-20150822-31376-1jl0ge0.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=284&fit=crop&dpr=1 600w, https://images.theconversation.com/files/92752/original/image-20150822-31376-1jl0ge0.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=284&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/92752/original/image-20150822-31376-1jl0ge0.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=284&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/92752/original/image-20150822-31376-1jl0ge0.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=357&fit=crop&dpr=1 754w, https://images.theconversation.com/files/92752/original/image-20150822-31376-1jl0ge0.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=357&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/92752/original/image-20150822-31376-1jl0ge0.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=357&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>A lack of regulation around e-cigarettes means that these products can potentially contain toxic chemicals. There are compounds in e-cigarettes which might ordinarily not be toxic but when delivered into the lungs during “vaping” might cause an as-yet unknown adverse effect. </p>
<p>Recent research published in the New England <a href="http://www.nejm.org/doi/full/10.1056/nejmc1413069">Journal</a> of Medicine suggests e-cigarettes which operate at high voltages emit significantly higher levels of cancer-causing formaldehyde than a burning cigarette. </p>
<p>Another study suggests the metal wick that is designed to heat up the e-liquid might actually release <a href="http://www.abc.net.au/news/2015-08-21/vaping-may-not-be-a-safer-option-to-smoking-adelaide-researcher/6713864">cancer-causing metals</a>) such as cadmium into the vapour, which is delivered into the lungs. </p>
<p>A separate <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0108342">study</a> has demonstrated that e-cigarette vapour may increase susceptibility to respiratory infection, especially in young children. </p>
<p>Electronic cigarettes might also have addiction-boosting compounds other than nicotine increasing their abuse <a href="http://www.sciencedaily.com/releases/2015/07/150722115527.htm">liability</a>. This is according to another study published in the American Chemical Society’s journal, Chemical Research in Toxicology.</p>
<h2>Why we need to regulate e-cigarettes</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/92753/original/image-20150822-31404-11zd2ee.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/92753/original/image-20150822-31404-11zd2ee.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=226&fit=crop&dpr=1 600w, https://images.theconversation.com/files/92753/original/image-20150822-31404-11zd2ee.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=226&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/92753/original/image-20150822-31404-11zd2ee.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=226&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/92753/original/image-20150822-31404-11zd2ee.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=284&fit=crop&dpr=1 754w, https://images.theconversation.com/files/92753/original/image-20150822-31404-11zd2ee.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=284&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/92753/original/image-20150822-31404-11zd2ee.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=284&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
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</figure>
<p>Should e-cigarettes not be regulated under the Tobacco Products Act, as is currently the case, South Africa could erode the gains from the current ban of cigarette advertisements and promotion. This would happen through brand-sharing with traditional cigarettes along with large adverts and promoting these brands. </p>
<p>Potentially there are two negative effects. South Africa could be creating an environment where cigarette brands are once again glamourised and smoking is re-normalised. But it also could encourage young people to smoke and promote the fashionable use of e-cigarettes. </p>
<p>The widespread availability of e-cigarettes may also encourage those who would have ordinarily quit smoking to keep puffing. They now have the opportunity to smoke these e-cigarettes in places where ordinary cigarettes have been banned.</p>
<p>The passive exposure to e-cigarette vaping has recently been shown to <a href="http://tobaccocontrol.bmj.com/content/24/5/501.abstract?etoc">evoke the urge</a> to smoke actual cigarettes. This finding supports the call by the UK to ban e-cigarette smoking in public places as this would contribute to reducing cues for smoking for those trying to quit cigarette smoking. </p>
<p>This, taken with the risk for accidental ingestion of e-liquid by an infant, makes it critical that regulatory intervention requires e-liquids to be in <a href="http://tobaccocontrol.bmj.com/content/23/suppl_2/ii4.full">childproof packaging</a>.</p>
<h2>A way forward</h2>
<p>The emerging evidence supports the regulation of e-cigarettes in South Africa, whether they contains nicotine or not. </p>
<p>The current scientific evidence to support the use of e-cigarettes as an effective mechanism to help smokers to quit is weak. But a regulatory approach should recognise the potential of these devices for the individual smoker who might want to use them to quit cigarette smoking all together. </p>
<p>The South African government would be wise to take action now before the use of e-cigarettes reaches epidemic proportions and their use reverses the gains of several decades of tobacco control.</p><img src="https://counter.theconversation.com/content/46509/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Prof Lekan Ayo-Yusuf receives funding from the South African National Research Foundation (NRF) and the USAID. He is also affiliated with the Harvard School of Public Health and the School of Health Systems and Public Health at the University of Pretoria as an Extraordinary Professor.</span></em></p>The regulation of e-cigarettes has been controversial across the world. As the South African government decides on its approach, there are pros and cons to weigh up.Lekan Ayo-Yusuf, Executive Dean (Interim), Sefako Makgatho Health Sciences UniversityLicensed as Creative Commons – attribution, no derivatives.