Abstract
It has been claimed by the promoters of electronic cigarettes that these nicotine delivery products are on a par with the implementation of syringe exchange to provide safe injection of heroin for drug users in the 1980s and that they are 95% safer than traditional cigarettes. 1 Faced with recent reports of death and serious illness associated with vaping, such claims must now be under serious scrutiny.
The first large-scale syringe exchange programme was introduced in Liverpool in 1986 in response to a perfect public health storm of mass youth unemployment and a flood of heroin hitting the streets together with the arrival of the hitherto unknown HIV virus bringing with it a devastating fatal disease with no known cure. The groups particularly affected were gay men, injecting drug users and workers in the sex industry, many of whom were also injectors. The goals of the ‘Mersey model of harm reduction’ were to make contact with the whole population at risk, maintain contact by developing therapeutic relationships and make changes in behaviour when patients were ready. The overriding consideration was that the spread of HIV was a greater danger to individual and public health than drug misuse. The approach was validated over the next five years, during which time the virus was to all intents and purposes kept out of the drug-injecting population of Merseyside in contrast to other parts of the country. 2 The situation with regard to tobacco and cigarettes and electronic cigarettes is altogether different.
Since electronic cigarettes became available 10 years ago, they have been aggressively marketed as a panacea for smoking cessation. There are now estimated to be 3.6 million British vapers in a rapidly growing market worth an estimated £15.7 bn. 3 The growth of this market has benefited from endorsement by both Public Health England and the Royal College of Physicians, with their continuing support for the claim that vaping is 95% safer than traditional cigarettes; a claim that is at variance to the position taken by the World Health Organization and many other countries. Over the last five years, while the debate over electronic cigarettes has smouldered, Public Health England opinion on the science appears to have been sought from a limited range of advisers, some with limited credentials and questions have been raised about conflicts of interest. We are stuck in two parallel universes with different belief systems at the highest policy making levels. So what are we to make of it all?
The comparison between syringe exchange and electronic cigarettes as forms of harm reduction makes a useful starting point. With syringe exchange, we were facing a devastating new disease with no known cure, potentially on a par with the Black Death of the Middle Ages; the alternatives to impure heroin in the form of methadone and pure heroin were well understood, and the risk of exacerbating levels of drug abuse by appearing to be condoning it was deemed to be justified; in addition, the approach adopted was to reach out to the whole drug-injecting population through regulated and publicly provided clinical services.
In contrast, when vaping made its appearance, the epidemic of tobacco use was waning in most developed countries, and public health education programmes on the dangers of smoking together with systematic programmes of smoking cessation had led to steady and significant decreases in smoking levels.
The aims of tobacco control programmes are to prevent people becoming addicted and to help people to recover from their addiction. The tests of any newcomer must be in comparison with this. Electronic cigarettes were introduced and promoted ‘without either extensive preclinical toxicology testing or long-term safety trials that would be required of conventional therapeutics or medical devices’.4 Containing highly addictive nicotine, they have been marketed in the same way as any other commercial product, albeit with attempts at age restrictions on access; no attempt has been made to restrict their use to existing tobacco users and the potential issues involved in recruiting new generations to nicotine addiction have been played down, at least in England. There are now 3000 vaping stores in Britain; these seem to have precious little to do with smoking cessation and much to do with promoting a seductive and edgy lifestyle with brands that are rapidly being integrated with other related lifestyle products and an ambiance that has more in common with a Chicago 1930s ‘speakeasy’ than a preventive health clinic.
Clinical pharmacologist D.R. Lawrence described the trajectory of new wonder pharmaceuticals hitting the market; from panacea, to ‘under no circumstances should this be prescribed’ to ‘under certain circumstances this may be of therapeutic benefit’.4 We are reminded of thalidomide, the benzodiazepine group of anxiolytics and others. It looks likely that electronic cigarettes are entering the second stage and that the claims made by their producers and the uncritical writers and agencies that have embraced them are about to be subject to much more scrutiny. In his recent comprehensive review of the respiratory effects of electronic cigarettes, Jeffrey Gotts et al reminds us that decades of chronic smoking are needed for the development of lung diseases and concludes that ‘current knowledge of these effects is insufficient to determine whether the respiratory health effects of electronic cigarettes are less than those of combustible tobacco products’.5
The time has surely come for those who have been so uncritical of electronic cigarettes to have the humility to reappraise their positions. The question of the role and safety of these products surely needs reframing?6