No smoke without fire
E-cigarettes are coming to your service shortly. Should we be concerned, asks Professor Howard Parker
It’s becoming clear that e-cigarettes are going to be very popular in the UK.
The market, already worth around $250m in the USA, is growing rapidly here. The majority of drug misuse service users are also tobacco smokers, part of the country’s 10m heavy smokers. Many will soon be seeing e-cigarette users in their social worlds and will be contemplating trying or using these new gadgets. The presence of e-cigarette use will in turn become an issue for our services.
E-cigarettes have prospered from being both outside tobacco regulation and new medicines approval. Regulation across the world is thus chasing rising consumption. There is no international consensus, so while strict sales restrictions are in place in Australia, Canada and some EU countries, in others like the UK there is essentially no national governance. Proposals for EU-wide regulation is a faraway promise whereby if any prohibition does emerge it will be after the ‘vaping’ market has been saturated and fully established and all the structures, if required to run an illicit market, have bedded in.
E-cigarette prototypes were created by Chinese pharmacists during the last decade and China continues to be the global supplier of a wide range of e-kits. In the UK, sales began via the internet and through small-scale retailers with market stalls, kiosks and small shops – usually in ‘poor’ areas. Still prohibited on eBay, these cigarettes are sourced from China mainly via Alibaba.com. However, while the small players are doing very well and expanding rapidly, so rich are the potential pickings that major companies like E-Lites have moved in. With recent national TV advertising and flashing billboards at Sky televised football matches to support a major growth in retail outlets, the vaping market is going to be very big business. Essentially we now have a product which has not been ‘approved’, and which is banned in many countries, on sale in Tesco and Morrisons.
For the uninitiated, e-cigarettes deliver a nicotine hit as liquid nicotine, held in a small cartridge. It is vapourised as the user pulls on their mock cigarette as if smoking normally. The delivery is powered by a cell or rechargeable battery. The ranges of products and kits are enormous and sophisticated. The upmarket paraphernalia, sold in supermarkets and garage forecourts, tends to be smartly packaged in mock cigarette-packets while other more industrial kits are found on market stalls. It will be interesting to see if regular users develop a psychological attachment to their paraphernalia, as we associate with drug-taking rituals around bongs and pipes. That the nicotine comes in multiple flavours including coffee and chocolate suggests suppliers have an interest in maintaining their customers and thus their profits. These profits will be made from starter kits priced at between £25 and £40 and the cost of replacement nicotine cartridges, on which a regular user will spend around £15 a week.
Intuitively a device that delivers nicotine without the carcinogenic chemicals in cigarette tar and smoke looks like a harm reduction winner for heavy tobacco smokers. If no major risks are identified from vaping, then eventually we may have a product which, when set in a CBT-type programme, aids smoking cessation and/or reduces morbidity. The market makers emphasise that vaping is very satisfying and suppliers argue that e-refills are cheaper than the heavy use of cigarettes. They indeed promote the harm reductions in switching to e-smoking, emphasising that there is no dangerous smoke to harm others and no legal restrictions on vaping in public places.
E-cigarette use will pose some interesting issues for health professionals in general and alcohol and drug services and smoking cessation programmes in particular. The harm reduction benefits are hard to dismiss for heavy smokers, yet e-cigarettes do not have a scientific clean bill of health, with key public health monitors and recent research studies urging caution. So it won’t be easy to form clinical views or provide information and advice packs about e-smoking.
Other knotty issues include: should services allow clients to vape on the premises or indeed bring the kits to appointments or on programmes, and if so at what age? Just recharging your G9 battery in the IT suite? Should staff be allowed to use e-cigarettes at work? Should vaping nicotine be included on assessment documents? How can e-cigarette use be recorded on databases without being lost in ‘other’? Should incidents of exploding batteries or clients dismantling the kits as part of risky behaviour be recorded and reported, and to whom? Should pregnant clients be advised to use or not use e-cigarettes as an alternative to their addiction to tobacco and/or cannabis? Are the kits to be considered a safeguarding risk, given drinking liquid nicotine can kill small children?
No doubt there’ll soon be a sociology PhD – e-cigarettes as a global symbol of postmodern consumption. For those working in the substance use and primary care fields, e-cigarettes bring harm reduction versus abstinence back into focus. Some intelligent pragmatism will be required in developing policy and practice and it will be worth listening to the first wave of vaping service users in trying to develop sensitive responses to their new habit. Better an e-cigarette than a crack pipe.
Professor Howard Parker has worked in the drug and alcohol field for more than 25 years as a lecturer, researcher, author, trainer and consultant.