E-cigarettes: a burning issue for future public health policy? Although some of the Labour party’s early thinking on public health policy has recently been leaked, in the run-up to the general election all political parties will need to develop their ideas for improving the public’s health, from policies on alcohol and food, to the role of industry and taxes. With plain (or rather standardised) cigarette packaging now close – in no small measure thanks to the compelling Chantler Review – the next political issue on tobacco must surely be a clearer view on e-cigarettes.
While there are concerns about the appropriate safety regulation of e-cigarettes, with recent reports of poisonings and fires, and issues about the standardisation of nicotine delivery, these concerns will be addressed by the EU Tobacco Products directive. The burning question is how the broader regulatory approach will develop and whether parties will be welcoming or shunning e-cigarettes?
The answer to that will depend to large degree on three issues: the role e-cigarettes play in introducing people to smoking (gateway effects); in encouraging people to continue smoking (maintenance); and in supporting people to give up smoking (exit effects). Views on these issues and the strength of evidence for each have been polarising the public health community. Some see e-cigarettes as renormalising smoking, especially for children, and it is striking just how many billboards are plastered with e-cigarette advertising, with ads making their way on to TV too. Others see e-cigarettes as the opportunity to help thousands of smokers to stop smoking,swapping a highly toxic product for a much less harmful, albeit highly addictive, one. There is also a contested middle ground, where people smoke both tobacco and e-cigarettes – is this reducing harm or stopping people from quitting tobacco entirely? Surrounding all of this there is, for many, a clear distaste for the commercial resurgence of the big players of the tobacco industry as they move into e-cigarette production.
In the past few weeks there has been a slew of new papers, surveys and other evidence on e-cigarettes, both here, and across the Atlantic. And today, 50 public health specialists have written to the World Health Organization supporting their use. So what does all this tell us? The latest survey by Action on Smoking and Health (ASH) – broadly in favour of e-cigarettes – has shown a huge increase in the numbers of adults using e-cigarettes since 2010 – now up to 2.1 million people across Great Britain, 700,000 of whom are ex-smokers. Around 38 per cent of those who had used e-cigarettes said they did so to help them quit smoking entirely. The same survey showed only 1 per cent of children who had never smoked a tobacco cigarette reported using an e-cigarette. ASH interprets this in a positive light in terms of e-cigarettes seeming to lead people into tobacco smoking, and Public Health England’s (PHE) review paper agrees, stating, ‘to date there is no data’ to support the claim that using e-cigarettes encourages people to start smoking tobacco. The PHE paper also sets out who uses e-cigarettes and how: use is more common among heavier smokers, younger smokers and ex-smokers. There is also evidence that e-cigarettes are used in preference to other nicotine replacement therapies, suggesting that people are using them as an aid to quitting or reducing smoking. Indeed, although subject to understandable caveats, the latest study suggests that quit rates with e-cigarettes may be as high as 20 per cent.
So, overall the message about e-cigarette use seems to be cautiously positive. But there are important subtleties that remain, especially among the 1.3 million people in Britain who continue to practice dual e-cigarette and tobacco use. Essentially, how big are the two groups of dual users: those who can’t or don’t wish to stop tobacco smoking and by switching some of their consumption reduce harm, versus those who would otherwise make ultimately successful quit attempts, but are stopped from doing so by being ‘maintained’ smokers? There has also been little debate or evidence to date on whether e-cigarettes narrow or widen socio-economic and other patterns of tobacco use, which is critical to wider health inequalities policy. We in England also need to keep abreast of how policy is shaping up further afield. For example, Public Health Wales has already called for a ban on e-cigarettes in enclosed public places and in the United States the balance of the policy debate (and seemingly the evidence) is clearly more anti e-cigarettes than it seems to be in the United Kingdom.
Getting the policy right on e-cigarettes is critical. Public Health England, recently criticised for being rather meek in big public health policy debates, will have an important role in navigating the tangled web of evidence and opinion as the parties start to develop positions on this critical issue. We therefore welcome the work it has commissioned in this important area, and the fact that it is starting to speak out. This debate is not going to go away, and much is at stake. Given that every tobacco cigarette smoked is estimated to reduce life expectancy by 11 minutes, politicians’ decisions on e-cigarettes will end up affecting the health of hundreds of thousands of people. The King's Fund
While there are concerns about the appropriate safety regulation of e-cigarettes, with recent reports of poisonings and fires, and issues about the standardisation of nicotine delivery, these concerns will be addressed by the EU Tobacco Products directive. The burning question is how the broader regulatory approach will develop and whether parties will be welcoming or shunning e-cigarettes?
The answer to that will depend to large degree on three issues: the role e-cigarettes play in introducing people to smoking (gateway effects); in encouraging people to continue smoking (maintenance); and in supporting people to give up smoking (exit effects). Views on these issues and the strength of evidence for each have been polarising the public health community. Some see e-cigarettes as renormalising smoking, especially for children, and it is striking just how many billboards are plastered with e-cigarette advertising, with ads making their way on to TV too. Others see e-cigarettes as the opportunity to help thousands of smokers to stop smoking,swapping a highly toxic product for a much less harmful, albeit highly addictive, one. There is also a contested middle ground, where people smoke both tobacco and e-cigarettes – is this reducing harm or stopping people from quitting tobacco entirely? Surrounding all of this there is, for many, a clear distaste for the commercial resurgence of the big players of the tobacco industry as they move into e-cigarette production.
In the past few weeks there has been a slew of new papers, surveys and other evidence on e-cigarettes, both here, and across the Atlantic. And today, 50 public health specialists have written to the World Health Organization supporting their use. So what does all this tell us? The latest survey by Action on Smoking and Health (ASH) – broadly in favour of e-cigarettes – has shown a huge increase in the numbers of adults using e-cigarettes since 2010 – now up to 2.1 million people across Great Britain, 700,000 of whom are ex-smokers. Around 38 per cent of those who had used e-cigarettes said they did so to help them quit smoking entirely. The same survey showed only 1 per cent of children who had never smoked a tobacco cigarette reported using an e-cigarette. ASH interprets this in a positive light in terms of e-cigarettes seeming to lead people into tobacco smoking, and Public Health England’s (PHE) review paper agrees, stating, ‘to date there is no data’ to support the claim that using e-cigarettes encourages people to start smoking tobacco. The PHE paper also sets out who uses e-cigarettes and how: use is more common among heavier smokers, younger smokers and ex-smokers. There is also evidence that e-cigarettes are used in preference to other nicotine replacement therapies, suggesting that people are using them as an aid to quitting or reducing smoking. Indeed, although subject to understandable caveats, the latest study suggests that quit rates with e-cigarettes may be as high as 20 per cent.
So, overall the message about e-cigarette use seems to be cautiously positive. But there are important subtleties that remain, especially among the 1.3 million people in Britain who continue to practice dual e-cigarette and tobacco use. Essentially, how big are the two groups of dual users: those who can’t or don’t wish to stop tobacco smoking and by switching some of their consumption reduce harm, versus those who would otherwise make ultimately successful quit attempts, but are stopped from doing so by being ‘maintained’ smokers? There has also been little debate or evidence to date on whether e-cigarettes narrow or widen socio-economic and other patterns of tobacco use, which is critical to wider health inequalities policy. We in England also need to keep abreast of how policy is shaping up further afield. For example, Public Health Wales has already called for a ban on e-cigarettes in enclosed public places and in the United States the balance of the policy debate (and seemingly the evidence) is clearly more anti e-cigarettes than it seems to be in the United Kingdom.
Getting the policy right on e-cigarettes is critical. Public Health England, recently criticised for being rather meek in big public health policy debates, will have an important role in navigating the tangled web of evidence and opinion as the parties start to develop positions on this critical issue. We therefore welcome the work it has commissioned in this important area, and the fact that it is starting to speak out. This debate is not going to go away, and much is at stake. Given that every tobacco cigarette smoked is estimated to reduce life expectancy by 11 minutes, politicians’ decisions on e-cigarettes will end up affecting the health of hundreds of thousands of people. The King's Fund
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