E-cigarettes and English exceptionalism

In the accompanying paper, Professor Gruszczyński reflects on the differing views about the European Union Tobacco Products Directive for e-cigarettes [1]. As he notes, there are some who see them as a means to end the smoking epidemic, while others view them as an instrument that is being used by the traditional tobacco industry to thwart this objective. He concludes that, given the continuing uncertainty about these products, the Directive is an appropriate response. We agree.
We would, however, add one important observation to his thoughtful review of the arguments being made by health organisations. Those whom he quotes as in favour of relaxing restrictions on e-cigarettes and, in some cases, even argue that they be promoted actively, are from one country, England. Yet even there, support for e-cigarettes is far from universal. Thus, the National Institute for Health and Clinical Excellence (NICE), which evaluates evidence on effectiveness of treatments, does not recommend them as cessation aids [2].
Elsewhere in Europe, and indeed also in other parts of the United Kingdom, concerns are widespread and are growing, for several reasons. First, there is growing evidence that these products promote nicotine addiction among young people, with some suggestion that this may be slowing or even reversing the long-term decline in smoking initiation [3]. Second, it has so far been impossible to find high-quality evidence that they increase cessation rates, with much of the available evidence suggesting they reduce them [4]. Third, evidence of their health risks is accumulating, especially in relation to lung and cardiovascular disease [5]. And finally, there are concerns about the enormous resources being used by the tobacco industry to promote them, and in particular the role of the Philip Morris-funded Foundation for a Smoke-Free World [6-8], coupled with the promotion of new products in the British markets designed to maximise nicotine delivery [9], as well as reports that e-cigarette manufacturers are emulating tactics traditionally associated with the tobacco industry [10].
There is particular concern about the now widely cited claim by Public Health England that e-cigarettes are “95% safer” than traditional cigarettes. As has been reported previously, this figure is based not on empirical data but on a meeting of individuals, some with links to e-cigarette manufacturers [11], whose report conceded that the evidence was insufficient to reach a robust conclusion [12]. Serious questions have been raised about the funding and organisation of this meeting [13]. The 95% safer figure has been repeatedly used by a small number of English organisations, justified only by the argument that the authors of their various reports have reviewed the evidence and agree with it [14]. This view is, however, far from universal even in England, with one team of respiratory physicians who have documented the adverse effects of e-cigarettes on lung function stating that “If we persist in the approach of Public Health England with its disregard for protecting the respiratory health of adolescents and young children, we are risking a further epidemic of devastating lung disease for today’s children” [15], while two leading toxicologists have described Public Health England’s promotion of e-cigarettes as “a reckless and irresponsible decision” [16].
European organisations have also been much more sceptical about the claimed benefits of e-cigarettes. The European Respiratory Society, responding to a paper in the British Medical Journal supporting the use of e-cigarettes [17], stated that “no-one, expert or otherwise, can credibly assert that e-cigarettes are safer than tobacco in the long term, given that they contain a whole new tranche of unregulated and unstudied compounds being inhaled into the lung” [18]. The European Heart Network also supports a cautious approach, advocating similar measures on marketing and price that have been effective in reducing smoking prevalence [19]. The European Public Health Association has stated that “It is not possible, at this point, to make any claims about the relative safety of e-cigs compared to traditional cigarettes. The overall effect may well be to worsen the tobacco epidemic first by deflecting smokers from using proven smoking cessation strategies and shifting them to e-cigs, which, for most smokers, reduce successful smoking cessation, and second by deflecting discussion from measures opposed by the tobacco industry” [20].
As with Brexit, a decision widely viewed as incomprehensible in the rest of Europe, some in England demonstrate a strong sense of exceptionalism in their attitude to e-cigarettes, as if the evidence from other countries does not apply to them. In both of these cases, some people seem willing to engage in an experiment on the health of the population. Others, meanwhile, will wait and learn from their experience.

DISCLOSURE

The authors report no conflict of interest.

References

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AUTHORS’ CONTRIBUTIONS

MM, DB prepared the research concept, wrote the article and approved the final version of the publication.