European Journal of Public Health, Vol. 24, No. 4, 534–535 ß The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

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Viewpoints

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Public health leadership and electronic cigarette users popularity turn out to be true in the longer term, electronic cigarettes could be a more effective intervention at a population level than other stop-smoking initiatives. The rise of the electronic cigarette is a consumer-led self-help public health movement, mostly spread by word of mouth, social media and direct point of sale advice at e-cigarette shops, with, until recently, little mass marketing. What other public health initiative could claim so many ‘converts’ in such a short time? This consumer public health movement is all the more remarkable because it has not used health care resources. It has not been a cost to taxpayers— being paid for by the consumer. This consumer-led public health initiative has all the hallmarks of what public health hopes to achieve. The core public health mission is to prevent disease, prolong life and promote health. Good public health initiatives work with individuals and communities. The WHO Ottawa Charter for Health Promotion states ‘Health promotion is the process of enabling people to increase control over, and to improve, their health . . . People cannot achieve their fullest health potential unless they are able to take control of those things which determine their health’.5 This seems to be exactly what electronic cigarette consumers are doing—taking control of things that determine their health. So it is also remarkable that this trend in electronic cigarette use has had little support from public health experts. Public health has yet to engage with this new movement. In many countries the medical and public health response has been negative and overprecautionary. The reasons for this are complex, but for people who have dedicated their lives campaigning against smoking and for an end of the tobacco industry it seems hard to accept that this disruptive innovation might be a solution to smoking. The caution exhibited by public health experts has led to a chasm between them and consumers: evidenced by comments on social media, many e-cigarette consumers see public health as the enemy of health and consumer choice. This should be cause for sober reflection by public health professionals and is an extraordinary situation that needs to be remedied from both sides to maximize the public health potential of safer alternatives to smoking. Conflicts of interest: Member of the UK National Institute for Health and Care Excellence guidelines development group on tobacco harm reduction; Director of K.A.C., a company that in 2012 received a smoking research feasibility grant from a company developing a nicotine delivery device.

References 1

Goniewicz ML, Kosmider L, Delijewski M, et al. The impact of the 2010 Polish smoke-free legislation on the popularity and sales of electronic cigarettes. Eur J Public Health 2014. doi:10.1093/eurpub/ckt214; [Epub ahead of print].

2

Huang J, Chaloupka FJ, Fong GT. Cigarette graphic warning labels and smoking prevalence in Canada: a critical examination and reformulation of the FDA regulatory impact analysis. Tob Control 2014;23:i7–12.

3

Kotz D, Brown J, West R. ‘‘Real-world’’ effectiveness of smoking cessation treatments: a population study. Addiction 2014;109:491–9. Available at: http://www. ncbi.nlm.nih.gov/pubmed/24372901 (7 January 2014 date last accessed).

4

Polosa R, Rodu B, Caponnetto P, et al. Fresh look at tobacco harm reduction: the case for the electronic cigarette. Harm Reduct J 2013;10:19.

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The recent study by Goniewicz and colleagues1 points to the increasing popularity of electronic cigarettes among people who want to quit smoking, adds to the growing scientific evidence about their real-world use and in turn raises questions about their potential to reduce smoking-related disease. Smoking is the leading cause of preventable death and disease globally, associated with nearly 6 million deaths annually; in the European Union smoking rates average 29% of the adult population, with 700 000 premature deaths each year. Most smokers want to quit smoking but find it hard to give up nicotine. Progress with reducing smoking continues, but the pace is slow. It is hard to see how the current non-communicable disease burden can be met without a drastic reduction in smoking prevalence. It is also hard to see how that can come about with current anti-smoking measures. The package of interventions in the European Tobacco Products Directive, including large health warnings and bans on small packs, is on the evidence of the European Commission’s own impact assessment likely to reduce tobacco consumption only by 2% over 5 years, which translates into 0.5% decline in prevalence in that time. Elsewhere, similarly modest historical gains have been demonstrated: graphic warning labels, introduced in Canada in 2000, are estimated to have helped reduce smoking prevalence by between 2.87 and 4.86% over 9 years, i.e. between 0.32 and 0.54 per annum.2 The contribution of conventional treatment interventions to reducing population prevalence of smoking appears negligible: in randomized controlled trials, nicotine replacement therapy (NRT) improves the chances of quitting, but in the real world of consumer self-initiated quit attempts, NRT confers no advantage over stopping without any aid.3 The jury is still out on whether NRT has had a measurable population-level impact. Population level declines in smoking are important but modest, and few could agree that the pace of reduction in smoking is fast enough. This means that countries face continued smoking-related morbidity and mortality for many decades. Where conventional ‘quit smoking’ approaches have lingered, electronic cigarettes are an attractive alternative to tobacco cigarettes for established smokers who are unable or unwilling to give up nicotine. The available evidence in this fast-moving scientific field indicates that electronic cigarettes do not raise serious health concerns and the science suggests that electronic cigarettes are many times safer than the smoked tobacco against which they are competing.4 They are clearly popular among smokers and exsmokers: in a short time there has been remarkable uptake in their use, with an estimated 7 million users in Europe and 1.3 million in the UK; in the USA, the value of sales is roughly doubling each year, from $20 million in 2008 to an estimated $1000 million in 2013. In the UK, Robert West’s Smoking Toolkit data show that electronic cigarettes have overtaken both NRT and health service stop smoking clinics as the most common resource used by people who want to stop smoking, with one in three quit attempts now involving the use of electronic cigarettes. Tobacco sales are declining, in part attributed to the rise of e-cigarettes, and the US stock market analysts estimate that e-cigarettes will overtake tobacco sales within 10 years. Trial results suggest that electronic cigarettes are at least as effective as NRT in a randomized controlled trial. However, RCT data alone are an insufficient basis for public health planning. An intervention needs to be effective, acceptable and capable of being adopted on a mass scale at low cost. If data on effectiveness and

E-cigarettes 5

World Health Organization. Ottawa Charter for Health. 1986. Available at: http:// www.who.int/healthpromotion/conferences/previous/ottawa/en/ (4 March 2014 date last accessed).

535

Correspondence: Gerry V. Stimson, Knowledge-Action-Change, 8 Northumberland Avenue, WC2N 5BY, UK, Tel: +44 78 72 600908, Fax: +44 20 83 322127. e-mail: [email protected] doi:10.1093/eurpub/cku049 Advance Access published on 11 April 2014

Gerry V. Stimson Emeritus Professor, School of Public Health, Imperial College London, London, UK and Visiting Professor, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK

......................................................................................................... European Journal of Public Health, Vol. 24, No. 4, 535–536 ß The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

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E-cigarettes: does the new emperor of tobacco harm reduction have any clothes? continuing to smoke: 80% of all who try vaping either dual use (vape and smoke) or go back to smoking, a message that would greatly please the tobacco transnationals who have now all bought into the e-cigarette market. We also have no good data on whether the availability of e-cigarettes might be causing lots of smokers who would otherwise have quit to prevaricate and dual use instead of quitting. What of the assumption that dual use at least reduces the number of cigarettes smoked? Does this not equate to harm reduction? While commencing age and pack years of smoking have long been known to be important dose–response predictors of health risk, prospective studies of reducing smoking (as opposed to cessation) counter-intuitively show poor evidence for risk reduction.3,4 Then there is the concern arising from some early signs of vaping uptake by school children who have never smoked,5 and the interests of the transnationals in fomenting a rebirth of the entire mystique of the smoking performance. We know the catastrophe of what tobacco marketing achieved with generations of children. We now see the very same tobacco companies scrambling to dominate the vaping market and to use exactly the same messages to sell e-cigs. Only the naı¨ve could be assured of negligible prospects of cross promotion. Harm-reduced tobacco and nicotine delivery systems have had an inglorious history of false starts. Each time consumers rejected them as poor substitutes for cigarettes, whatever the promises they claimed. None were commercial successes. E-cigarettes may well be spectacularly so, but as always, the woods need to be seen from the trees. Everyone wants to see tobacco’s harms reduced. But if the undoubted benefits to some are at the expense of stalling or reversing the huge progress that has been made in reducing smoking prevalence in past decades, the net effect may not be positive. Conflicts of interest: None declared.

References 1

Brown J, Beard B, Kotz D, et al. Real-world effectiveness of e-cigarettes: a population study. Abstract PA18-4 from Society for Research on Nicotine and Tobacco conference, 20th Annual Meeting, Seattle Feb 2014. Available at: http:// nicotinepolicy.net/commentary/86-g-krol/861-new-research-shows-electroniccigarettes-better-for-quitting-than-no-aid-over-the-counter-nrt-worse-than-no-aid (14 April 2014, date last accessed).

2

Grana RA, Popova L, Ling PM. A longitudinal analysis of electronic cigarettes and smoking cessation. JAMA Int Med 2014. doi:10.1001/jamainternmed.2014.187. Published March 24.

3

Pisinger C, Godtfredsen L. Is there a health benefit of reduced tobacco consumption? A systematic review. Nicotine Tob Res 2007;9:631–46.

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Gerry Stimson chides the health and medical communities for what he sees as deplorable lack of leadership in embracing and supporting the rising popularity of electronic cigarettes as a harm reduction tool. He thinks a lot of this has to do with those who have worked all their professional lives in tobacco control feeling blindsided by a disruptive technology that we had nothing to do with. We are apparently so gracelessly self-absorbed and small-minded in maintaining support for the glacial pace of our woefully inept suite of comprehensive tobacco control policies (now embraced by a mere 178 nations via the World Health Organization’s Framework Convention on Tobacco Control), that we need to ‘soberly reflect’ on our myopia and sound the trumpets for a driver of cessation and harm reduction of such promise that the world has never seen. His essay has a lot to say about the dramatic rise in ‘popularity’ of e-cigarettes and their promise in turbo-charging smoking cessation. However, amazingly, it is silent about the two core premises of that promise: the claims that e-cigarettes greatly improve the odds of successfully quitting compared with either unassisted cessation or using pharmaceutical aids like nicotine replacement therapy; and the apparently self-evident truth that reducing daily cigarette consumption by vaping while also continuing to smoke will reduce the risk of disease and early death. Let us take cessation first. Stimson and other vaping advocates valorize the emergence of the vaping ‘community’ as a kind of selfhelp movement of chemical hobbyists trying to reduce health risk. The blogosphere and social media that impress Stimson are frothing with excitement from former smokers celebrating the end of smoking in their lives, thanks to e-cigarettes. But it is wise to reflect that these online communities are a self-selecting tiny fraction of those who have used these products. Just as winemaking sites tend not to overflow with those whose efforts to produce drinkable wine failed, vaping sites are thin on admissions from those smokers who are still smoking pretty much as before. There are now six population-based longitudinal studies or RCTs of variable size and quality on how many smokers who try vaping actually stop smoking. By far the largest and most important of these is the UK Toolkit study that Stimson cites (only the abstract has so far been made public1). He correctly tells us about the emerging popularity of e-cigs as a cessation method, but says nothing about their success. The Toolkit study found that of smokers who made a quit attempt in the past 12 months, 19.9% of those using an e-cigarette succeeded compared with 15.1% of unassisted quitters and 10% of OTC NRT users. Other studies report only marginal advantages of e-cigarette use over other cessation strategies, or worse outcomes.2 A 4.8% absolute or a 24% relative improvement over unassisted quitting is encouraging, but it is hardly a cause to cast off all caution. By far the most likely result of trying to quit via e-cigarettes is

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