23 October 2019

‘Straw men burning’ in Europe’s vaping debate

Addiction Respiratory

The European Respiratory Society (ERS) sees so little complexity in the vaping debate, it can express its position statement in one word: Don’t.

That ‘Don’t’ was presented on a slide in metre-high type at the ERS Congress in Madrid, by Jorgen Vestbo, professor of respiratory medicine at the University of Manchester and former ERS president.

At a session that was packed despite being convened at the last minute, Professor Vestbo, chair of the ERS’s advocacy council, said those who feared vaping was harmful should not have to prove it; rather, the precautionary principle should apply.

He said while no-one could be against reducing harm, the harm-reduction case was based on flawed and factually incorrect arguments.

Countering these, he said there was a lack of evidence that e-cigarettes were effective for smoking cessation and that none had been approved for that purpose; that many users of e-cigarettes and smokeless tobacco continued to smoke; that nearly all non-industry-funded studies found some level of harm and there was no evidence about long-term health effects; and that traditional means of curbing tobacco use was working.

He said the true target of smoking cessation was nicotine addiction, and many studies showed that those who switched to e-cigarettes continued using them rather than giving up nicotine altogether. “E-cigarettes seem safer,” he said. “But what is not?”

To loud approval from the audience, Professor Vestbo said the ERS, which published a position paper in May, had decided to treat funding from makers of e-cigarettes as equivalent to funding from tobacco companies, which excludes recipients from membership.

Earlier in the session, David Christiani, a professor of medicine and environmental genetics at Harvard University, spoke about the outbreak of acute lung disease in the US, which now involves more than 800 cases in 46 states and has caused 13 deaths.

He called this “an acute epidemic on top of a chronic one”, and said intervention was necessary to deter vapers while research continued to find the culprit.

This was proving hard as the patients’ pathology and imaging were very variable, as were the products they had used.

A high proportion had used THC liquid, which was sometimes mixed and diluted by the user, and attention quickly focused on vitamin E acetate; but Professor Christiani said officials had jumped the gun to blame that compound, which was found in only 10 of 18 samples tested.

“After this acute epidemic is brought under control we need to stay focused on the chronic health effects [of vaping],” he said. “Nicotine products are not off the hook, even if it looks like it’s mainly THC.”

Professor Martin McKee, from the London School of Hygiene and Tropical Medicine, also gave a video presentation about “English exceptionalism” on the subject – chiefly Public Health England’s endorsement of the estimate that vaping is 95% safer than smoking, and its promotion of vaping as a quitting aid. 

All questions and comments from the floor were in tune with the presenters, except for Dr Nicholas Hopkinson, respiratory physician and chair of the board of the UK’s Action on Smoking and Health, who courageously put the opposing view.

He said he could smell smoke in the room “from straw men burning” and that in fact England did have something to say to Europe, where smoking rates were higher, there was no standardised packaging and smoking was still allowed in cafes.

“We want strong statements from the ERS about that as well,” he said.

The UK’s smoking rate was just under 15% in 2018, according to its Office of National Statistics, while the EU’s is 19% – ranging from 8.7% in Sweden to 27% in Greece – according to European Commission figures from 2014.

After the session Dr Hopkinson told The Medical Republic that while the e-cigarette problem was “new and interesting”, smoking was on track to kill a billion people this century.

“So we need to stop that and we know what works,” he said. “You have to put up prices. You have to ban advertising. You have to keep the tobacco industry out of policy. And you have to help people help to quit.” He said while vaping was often said to be the biggest disruptor to the tobacco industry, really it was high prices such as those in Australia and the UK.

“That’s what’s so frustrating: you have a country [the US] where the basics of tobacco control are not being implemented, but people are very worried about vaping.”

He said the US deaths were tragic, but the outbreak, which appeared to be specific to the US, represented a failure of regulation.

In the UK where it was tightly regulated, it was “vanishingly rare” for children and adolescents to vape who hadn’t previously smoked.

“It doesn’t seem to be something that has established itself as a cool behaviour in, in the UK yet. Now in the US, maybe because a much wider range of advertising has been allowed, these are now cool products.

“There are a lot of unknowns, and I think there’s no doubt that if you take a 15-year-old now and they start vaping and they continue vaping for 50 years, that’s going to cause them health problems. But if that 15-year-old starts smoking, we know that takes 10 years off their life, they’re likely to need social care 10 years earlier, and 50% of smokers die from a smoking-related disease.”