Electronic cigarettes and harm reduction- the debate continues
On June 24th the BMJ published a feature article on the controversies surrounding the use of electronic cigarettes (e-cigs) for harm reduction among smokers of tobacco cigarettes (“Why e-cigarettes are dividing the public health community” by Jonathan Gornall). The article describes the firestorm created when an open letter was sent to the director general of the World Health Organization arguing that harm reduction strategies, even those that required partnering with the tobacco industry, were being overlooked as an effective approach to tobacco control. An immediate contrary response came back from over 100 public health experts decrying harm reduction and pointing out that the tobacco industry has used this strategy before… presenting itself as a partner for public good while continuing expanding its core business of selling tobacco cigarettes. At the heart of the harm reduction argument is the use of e-cigs as a substitute for tobacco cigarettes. Among the many problems with this strategy (e.g., are e-cigs effective for smoking cessation or harm reduction, and are they safe?) is one chief problem—the likely partner for developing a scalable e-cig harm reduction plan is the tobacco industry.
Many experts in the UK, as the article points out, are fully behind collaboration with BAT offshoot “Nicoventures” believing that the company has the ability to manufacture a medicinal e-cig on a scale large enough to meet the goals of tobacco harm reduction. Opponents are sceptical of the harm reduction model and highly critical of the partnership with BAT and Nicoventures. I fall into the camp of the sceptics.
I can understand the argument for harm reduction—many (though not all) of the adverse effects of smoking are dose-dependent. If a smoker reduces exposure to tobacco cigarettes over a lengthy period, adverse health effects may be reduced. If this effect can be multiplied across a large population the public health would benefit. There is no evidence that e-cigs can achieve either goal. I’d argue that we should begin accumulating evidence to support or refute the potential benefit of widespread use of e-cigs. Adopting the stance that e-cigs should be promoted now by clinicians and public health advocates is unsound science and unsound public health policy.
The issue I have the most trouble with is partnering with the tobacco industry in this effort. There is no doubt that an industry giant like BAT can manufacture e-cigs on a large scale and conform to good manufacturing practice to produce a standardized e-cig product. This might be a welcome change compared with the current marketplace where there is no regulation, and no standards for the e-cig devices or solutions used in them.
But effective collaborations and partnerships require much more than technical ability—the partners must be aligned with common interests and a high level of trust that each party will always live up to these interests. The tobacco industry is not a trustworthy partner for ensuring the public health or reducing the harms from tobacco. Their core business is selling cigarettes and their strategy is to expand markets, particularly in low and middle income countries and among young people. It’s a completely logical strategy for a business that has to replace almost 5 million regular customers who die from tobacco caused diseases every year.