Is this what we want to see?

Among those involved in public health who see it as their task to ‘control’ tobacco by supporting measures to ‘drive down smoking rates,’ as they put it, a new refrain has arisen that has almost become a mantra: e-cigarettes are 95 per cent safer than smoking tobacco!

Some tobacco controllers get a bit carried away by this figure. We have the self-styled world expert on smoking and addiction, Professor Robert West, a psychiatrist, who is on record as saying: ‘If we fail to take this opportunity that electronic cigarettes are potentially providing then we’re really condemning [smokers] to death.’

Condemning smokers to death? Do we line them up against a wall or string them up from lamp-posts? What I guess he means is that if we (whoever ‘we’ are) fail to take this opportunity, etc., then you, the smoker, are going to die because e-cigarettes are not available because of unprogressive legislation or because it was believed they were dangerous when they weren’t.

What an strange idea. Because we don’t all rush to embrace e-cigarettes, many unfortunates who are suffering from the incurable disease of smoking will die. But all they have to do, to avoid an untimely death from this cause, is to stop smoking (unless they’ve left it too late of course).

Then there is Dr Colin Mendelsohn (https://www.nicotinemonkey.com/tobacco-treatment-specialist) who, likewise, believes in treating smokers with nicotine. He recently said in an Australian podcast: ‘[E-cigarettes are] a life-saving technology which allow people who can’t quit smoking to switch to a much safer alternative. We know that they’re at least 95 per cent safer than smoking.’

Where does this nice round figure of 95 per cent come from?

It first appeared in 2015 in a report issued by Public Health England called E-cigarettes: an evidence update, in which these drug delivery devices are promoted as a ‘tool’ for smoking cessation. The lead author is one Ann McNeill who, in these days of super-specialization, is a Professor of Tobacco Addiction at King’s College London. We’ll come back to her in a moment.

Another author is the clinical psychologist Professor Peter ‘nicotine-itself-is-harmless’ Hajek who, though he denies links with any e-cigarette manufacturer, has received research funding from and provided consultancy to manufacturers of so-called stop-smoking medications.

The Public Health England report was strongly criticized in an editorial in the prestigious medical journal The Lancet, which pointed out that the report’s conclusions were based on a study of ‘the opinions of a small group of individuals with no pre-specified expertise in tobacco control.’ Oh dear.

Now it turns out that this study was led by none other than the well-named and eccentric neuropsychopharmacologist (sic), Professor David Nutt, who in 2009 was dismissed as chair of the UK government’s Advisory Council on the Misuse of Drugs after saying that ecstasy, cannabis, and LSD are less dangerous than alcohol and tobacco. He also believes that the psychedelic drug, psilocybin, can be useful in treating depression. Furthermore, two of the portly Professor Nutt’s colleagues are mentioned in The Lancet editorial as having potential conflicts of interest due to their associations with an e-cigarette distributor and manufacturers of smoking cessation products, respectively. Oh dear again.

The original ‘95 per cent’ article (Nutt, D.J., et al., Estimating the harms of nicotine-containing products using the MCDA approach. European addiction research, 2014. 20(5): p. 218-225) is an account of a theoretical exercise at a two day workshop in London in 2013. The participants used a complicated statistical formula and arbitrary criteria whereby, somehow, if ordinary cigarettes are regarded as 100 per cent harmful, e-cigarettes are only about 5 per cent as harmful. They did at least admit that ‘Our understanding of the potential hazards associated with using electronic nicotine delivery systems is at a very early stage.’ Quite.

The British Medical Journal also weighed in with an aptly titled article, Evidence about electronic cigarettes: a foundation built on rock or sand? The authors point out a number of potential serious problems with e-cigarettes, among which are (paraphrased):

  • Children and adolescents may take up e-cigarettes and progress to smoking
  • The long-term effects of e-cigarettes are unknown
  • E-cigarette liquids contain formaldehyde as well as flavourings and other substances which may be harmful to health
  • If e-cigarettes are used to reduce smoking, as opposed to quitting, there may be no overall benefit for health
  • There is no evidence that e-cigarettes are effective as aids for quitting smoking
  • There may be a risk to bystanders from second-hand vaping in enclosed public places

Of course Professor Ann McNeill was not going to take this lying down. She became very cross at all this criticism of her ‘e-cigarettes are at least 95 per cent safer than smoking tobacco’ claim, especially at The British Medical Journal article which she called offensive.

The same confused attitude of the medical establishment to so-called recreational drugs is reflected in a cringe-worthy sentence in an article in The British Medical Journal (28 January 2017, p 156) on ‘Novel psychoactive substances (NPS)’, or ‘legal highs’ as they are inaccurately known. In Britain it is illegal to distribute or sell them but possession is not a criminal offence. This being the case, the authors apparently think use of these substances is part of normal life, for there is a box headed ‘Information for patients who ask about NPS’.

This scenario is extraordinary. Can you imagine a patient making an appointment to see his or her GP and then saying something like: ‘Doctor, I’m think of using a “legal high” at a party this weekend. Could you please advise me how to do it.’

In spite of the fact that a large part of the article is taken up with a discussion of the risks and dangerous side-effects of these substances, this is the advice: ‘If using a novel substance, as with any drug, start with a very small dose and increase to obtain the desired effects.’

There is only one word a doctor should say to anyone planning to use such drugs: Don’t.

But it seems with the addictive drug nicotine, because distribution, selling, and use are at present legal, according to the Public Health England report, ‘it would be preferable for a young person to use an e-cigarette instead of smoking.’

How about not using nicotine at all, in any form?

Text © Gabriel Symonds

Photo by Philafrenzy, https://commons.wikimedia.org/w/index.php?curid=45613779