Public Health

Another day, another polarising piece on e cigarettes

Should we recommend e-cigarettes to help smokers quit. A useful, if polarised, yes / no article in the BMJ. The rapid responses are better, and more polarised

Meanwhile the public get a confusing message.

I get there are differences of view, I get that we all want to do the right thing, there are different interpretations of “right” In this one.

Prof McManus’s masterful blog – How and why I changed my mind on e-cigarettes – is as good a place as any to form a middle ground on. It has been exceptionally influential in this space in the view of many of my colleagues. I often encourage people to read the Science Media Centre for reaction to some of the most “interesting” stories. They don’t cover everything, but they do cover a lot of stories in this space. Science on this is accumulation all the time, most recently from the US National Academies. Good summary here, note the concerns re long term net benefit.

Everyone has a view. This commentary from a social media active respiratory physician is well worth a read. Though its uncomfortable reading for the PH profession, Clive Bate’s blogs are good (if a little long and technical) on this.

Disquiet and confusing public narrative continues on e cigs and the net benefit or harm. See Soneji et al Quantifying population-level health benefits and harms of e-cigarette use in the United States for example. For me seems to overfocus on the number of kids starting vape – convert to smoking and skirt over the uncertainties re long term quitting – nobody really knows at 7y, nobody will fund the studies -no commercial interest etc.

Poor quality media reporting on these studies abound. See here from Bloomberg. Then look at the Science Media Centre expert reaction to modelling study on electronic cigarettes in the US

There are media stories of vapers getting popcorn lung (whatever that is) that get everyone excited.

Is it any surprise the public are confused.

But Doing nothing doesn’t seem a credible option. An effort to strike a position on the matter in Sheffield

thus the options are to take a position at either end of the polarised continuum or to try to seek a middle space. This is what we are trying in Sheffield.

In an effort to strike a sensible position on this divisive issue Sheffield Tobacco Control Board has published an updated consensus statement. We are aiming to be a vape friendly city.

The statement is here along with info leaflets. Please feel free to steal them, if you improve them please share your improvements.

We know we haven’t got it all right yet, but remain committed to that path.

My general view is:

1. The best thing to do is stop smoking. The end.

2. There is long term evidence tobacco kills people.

3. E cigarettes would appear on the basis of what we know to be safer.

4. Many are unable If people are able to switch and they make an informed choice based on what we seem to know, and it works for them, power to them

5. The science may change and develop , we should then change our view if it does

6. The counterfactual is critical – what are we comparing to…. Continued smoking?

7. Obviously dual use is problematic – you are only cheating yourself etc.

8. Of course there may be residual scientific uncertainties, of course there are issues of whether the product is 95% safer – is it 95%, 96% or 84% – there is no way of being precise about this. Arguably we don’t yet have the methodology to be precise. However, I don’t have the ability to do any better, so I mostly stick with the line of substantially safer

9. The line re medicinal product v consumer choice is important one. Regulation in UK is far better than in states, but still not perfect

10. The TPD gives a bit more rigour on regulation than is the case in USA. There’s an interesting debate to be had on why there was divergence of view between USA and UK. A story for another day.

11. Pregnancy is tricky. But again – whats the comparator…. Continuing smoking? The same issues as per NRT about 20 years ago? The line of pragmatism that most seem to have reached seems about right to me. On pregnancy see here for punchy infographic (could easily be for all smokers).the longer version is still good.

12. E cigarettes have no place being promoted in children.

I Agree with the worries some express re kids and gateway to smoking. There’s little to no credible published evidence that vape is enouraging kids who would otherwise NOT have started smoking. If youre going to start something, staring vaping, better than smoking. But vaping has NO place in children, it is a product for smokers to move away from smoking. There is little evidence re gateway effect INTO smoking. And plenty of evidence re gateway out of smoking.

I agree with views others have expressed re normalising vaping in kids. Nobody wants this. Strong messaging needed. We are doing a bit of work on that front, but could boost.

We are doing surveillance on uptake as part of our annual every child matters survey, data is available. We would like to do more robust surveillance but don’t have the resource.

See here for the CRUK funded research finding little to no evidence supporting a concern that e-cigarettes are a ‘strong gateway’ into smoking

The evidence does not therefore support the concern that e-cigarettes are a strong gateway into smoking. In the UK sale of e-cigarettes to under-18s is prohibited, and advertising for e-cigarettes on TV, radio, the internet and the press is prohibited. All of these measures are designed to protect young people in particular

Approach to enforcement in sales to minors.

We know 44% of Sheffield traders sold e-cigs or related products to young people as part of a test purchase operation conducted by a national newspaper. Locally we are seeking better intelligence and enforcement by working with Trading Standards to conduct test purchases on underage sales for e-cigs on a sample of local shops/supermarkets and pop ups.There is a maximum fine of £2,500 for selling the products to minors. We have a clear process in place for enforcement. We advise local e-cig traders of their requirements in order to meet the TPD. Those who fail test purchases are informed of what they need to do to improve and ensure they comply with the law. Following this they are sent a letter spelling this out. In addition they are test purchased again within a 3 month period. We work with traders and ask them to keep evidence of the number of refusals they have conducted to demonstrate compliance with the law. When we have prolific offenders we prosecute. We have not yet had to take this route but this also a fairly new law.

I still hear plenty of clinicians worried about suggesting e cigs on the grounds of long term safety fears

My standard line is this:

  1. I’m also, TBF, concerned about long term impact of e cigs, but my concern is principally around kids and gateway into smoking. There is little evidence that this is an issue on any scale.
  2. Equally Im concerned about the counterfactual – the long term impact of continued smoking…….
  3. This re adult / cessation aid / route out of smoking  with current state of evidence (esp see the recent NEJM study) I don’t think inaction on e cigs is an ethical option
  4. Yea I get the first do no harm principle, but continued smoking and not addressing does harm etc
  5. So I frame it in 1) counterfactual and 2) ethical framework (including patient autonomy) – benefit, harm, autonomy, justice

So wrapping up

The balance of evidence is that swapping is safer, hence the advice remains stop and stop for good, for some swapping seems a decent place to start in that. People can make adult choices. Of course there are concerns about children starting vaping. We must be practical and measured about all of the above things.

It seems large numbers of people are switching to what they believe on the basis of the available science to be a safer alternative.

Doing nothing doesn’t seem a credible option, thus the options are to take a position at either end of the polarised continuum or to try to seek a middle space. This is what we are trying in Sheffield.

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