No smoke without fire?

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No smokingIs the Welsh Government right to propose a ban on the use of e-cigarettes in public places, or does it risk seriously undermining tobacco harm reduction? 

E-cigarettes are marketed as a safer alternative to ordinary cigarettes and regarded by some as a key element of tobacco harm reduction. The campaigning charity Ash (Action on Smoking and Health) states that ‘there is little real-world evidence of harm from e-cigarettes to date, especially in comparison to smoking,’ and NICE supports the use of licensed nicotine-containing products as a harm reduction measure.

The Welsh Government’s public health white paper, however (see news story, page 4), now proposes restricting the use of e-cigarettes in public places to address concerns that they ‘normalise smoking’ and ‘undermine the enforcement’ of the country’s general ban on smoking in public places. ‘E-cigarettes contain nicotine, which is highly addictive, and I want to minimise the risk of a new generation becoming addicted to this drug,’ said health minister Mark Drakeford.

While Ash has welcomed the white paper consultation and attendant debate, the charity has also stated that it ‘hasn’t seen much evidence’ that e-cigarettes are normalising smoking behaviour. ‘I know a lot of people have expressed concerns, and as more and more products have come on the market inevitably there has been a rise in usage, but we’ve conducted surveys regularly since 2010 and among adults certainly there’s no evidence of non-smokers being interested in using them, and among young people it’s almost the same,’ Ash spokesperson Amanda Sandford tells DDN.

Those young people who have expressed an interest in, or tried, e-cigarettes are ‘nearly always’ the same young people who have already tried smoking, the charity has found. ‘The situation may change, of course, which is why we need to keep monitoring it, but so far it seems that there isn’t the evidence to support the hypothesis that it’s encouraging the take-up of smoking,’ she says.

What about the Welsh Government’s argument that use of e-cigarettes in public places undermines enforcement of their smoking ban? ‘Again, it would be interesting to see if they can provide examples of that,’ she says. ‘Obviously, there’s a range of approaches to e-cigarettes but we don’t think it’s appropriate to have them regulated under the smoke-free legislation because that was designed to protect people from second-hand smoke, which it has done – compliance rates have been extremely high. These devices don’t contain tobacco so there’s no passive smoking issue – yes, they produce vapour but it’s essentially water vapour with a small trace of nicotine and there’s no evidence that we’re aware of that that causes any harm at all.’

What the charity does support, she stresses, is regulation, and it has just responded to a consultation by the Committee on Advertising Practice on the marketing of e-cigarettes. ‘We do think it’s appropriate that there are restrictions on how the devices are marketed – they’re mainly used as an aid to cutting down or quitting smoking and we think that it’s appropriate that they be marketed in that way, rather than as a lifestyle product or something young people might want to use.’

Cancer Research UK, however, published a report last year, The marketing of electronic cigarettes in the UK, warning about the use of channels likely to appeal to young people, such as competitions and mobile phone apps. ‘Arguably, some of these products are being marketed in an irresponsible way but the reason we think it’s more appropriate to have them licensed as medicines is that that process would impose regulations on the product in any case,’ Sandford states. ‘If you have a product licensed as a medicine, companies would be able to market it but in a strictly controlled way, and there would have to be controls to make sure it wasn’t directly aimed at young people.’

Co-author of the Cancer Research report, Professor Gerard Hastings, also pointed to what some see as a potentially wider problem – the general dangers associated with big tobacco companies moving into the e-cigarette market. ‘From past experience we know they are deceitful, determined and deeply detrimental to public health. E-cigarettes could provide them with the cover they need to regain the powerful position they once had – in which case a Trojan horse will rapidly become a Trojan hearse,’ he said.

‘I think that is quite an important issue,’ acknowledges Sandford. ‘I’ve read reports from the US, for instance, that the industry could be using them as an alternative means of brand sharing. That wouldn’t be permitted in this country, because we have a ban on tobacco advertising, but the tobacco companies often talk about harm reduction and there’s not a lot of evidence that they’re really serious about it – they’re obviously interested in getting into the e-cigarette market because they can see the potential to make money.

‘If they were all to say, “OK this is the way forward and we’re going to abandon cigarette production and move wholesale into e-cigarette production” then we wouldn’t have a problem with that,’ she continues. ‘But I don’t think that’s a very likely scenario in the foreseeable future, so we do need to be mindful of how the industry’s approaching this and question quite vigorously what their motives are. If they are serious about harm reduction, are they going to move into alternative nicotine delivery devices and stop production of the product that we know kills people?’

Consultation at wales.gov.uk

The marketing of electronic cigarettes in the UK at www.cancerresearchuk.org

See comment by Neil McKeganey.