Reducing Tobacco Harm
By Dr. Terry Maguire, a Northern Irish Community Pharmacist, senior lecturer at School of Pharmacy (Queens University Belfast) and Belfast LCG member.
Smoking remains a stupid thing to do since it kills over 2,000 in N. Ireland and some 6,000 on the Island each year which beats the annual killing rate of our best paramilitaries in their hay-days – and it does this every year – no ceasefires. But in addition to death – which costs the health service more or less nothing – smoking makes people very sick; with cancer, lung disease and cardiovascular problems which does cost a lot. But smoking is unfair as it is a key reason why poor people have poor health. In our most deprived council ward – Whiterock in West Belfast where my pharmacy is – 54% of the residents smoke while in the homes of the rich and famous- the horsy-headscarf and green-welly brigade of North Down – less than 10% smoke.
In 2013 the UK National Institute of Clinical and Health Care Excellence (NICE) published a Tobacco Harm Reduction Strategy that recommended; stopping smoking, cutting down to stop, smoking reduction and temporary absence as acceptable ways of reducing tobacco harm and to use licensed NRT to support these approaches. The NICE strategy while accepting that some smokers might find quitting difficult, stopped short of recommending e-cigarettes.
The law on plain packaging, if passed, will make cigarette packs look like something fished out of a sewer and seems to be a watershed for Big Tobacco (BT). Rather than fighting the law with its usual noisy denials, BT are changing the game. Smoking is bad for health, they now say. With refreshing honesty, spokespeople from BT admit they don’t smoke or, if they do, would prefer their children didn’t. It is BTs responsibility, they feel, to develop harm reduction strategies. The Pope converting to Islam springs to mind.
And this is where e-cigarettes fit in. We must understand that e-cigarette technology has been captured by BT as a new weapon on a new front. BT hopes to use this technology to turn conventional smokers into a vapers and save their lives yes but also keep them smoking cigarettes. Yes you can have it both ways. BT’s new frontline is harm reduction and it is out enrolling new allies.
Community pharmacy is struggling with e-cigs and unsurprisingly is finding difficulty deciding which way to go. Public Health itself is undecided; a letter in the London Times in May signed by 50 top scientists asked for minimal regulation of e-cigs as there could be huge public health gains. However, we all need to ensure that we don’t set ourselves up as naive hypocrites and apologists for an industry that has insisted for over 50 years that it’s product was neither dangerous, addictive or that they recruited children as new smokers.
Continuing smokers face a 50:50 chance of dying as a result of their habit but half of deaths occur before 60 so many smokers don’t have to wait too long. Dementia is less common in smokers; now you know why. While smoking kills the risks associated with continued NRT use are negligible. But the current range of licensed NRT products/formulations were designed from the outset to minimise the risk of abuse and dependence and therefore do not offer smokers a ‘satisfying’ alternative to cigarettes. E-cigarettes caters for that smoking satisfaction such as the “throat catch” a desirable part of the smoking experience.
At best the use of e-cigarettes offers the potential for a significant reduction in the public health burden of tobacco use; a 25% reduction in CHD, 40% reduction in cancers, 80% reduction in lung cancers and a 90% reduction in COPD prevalence. This will only happen if all tobacco smokers switched completely to e-cigarettes which is highly unlikely. Nonetheless it would still be a very attractive proposition even if 10% did.
On the risk side e-cigarette use might; inhibit smoking cessation efforts, prove more dangerous in the long-run, be a “gateway” to cigarettes for the kiddies. And some medical, professional and public health organisations; pharmacy bodies included, are far from enthusiastic. Add to this the long held view by many that Big Tobacco, who own most of the e-cigarette companies, are as trustworthy as a politician with a lost wallet and the current confusion becomes understandable. Let’s be clear Big Tobacco’s commitment to “harm reduction” is merely a ruse to maintain market share of core business – the sale of tobacco.
E-cigarettes might be safe but we just don’t know. Nicotine solutions have been found to contain tobacco-specific nitrosamine and diethylene glycol – antifreeze is good for your car in winter but in your lungs? Nicotine levels vary from product to product and liquid vials may contain as much as 60mg of nicotine which would easily dispatch any child who accidently drinks it and reports from Emergency Departments suggest this is very possible. They also go on fire which is not good if you’ve plugged it into your computer to charge overnight downstairs.
In the UK over 2.1 million people have already tried e-cigarettes with some 700,000 regular users and this will prove to be a huge market perhaps currently running at £70million a year. Many pharmacies; multiples and independents, have ignored professional advice not to sell e-cigarettes until licensed and are currently doing so. But the claim they are only looking after their patients; off course they are.
MHRA is committed to licensing e-cigs by 2016 and across Europe there will be regulation but as yet this might not apply to all products.
Do they work? Clearly the harm reduction benefit of e-cigarettes, given our deep understanding of the harm from smoking tobacco, is intuitive logic and yet there is currently no evidence. An evidence-base for a role in smoking cessation is slowly emerging but often this evidence is conflicting and studies are of poor quality. Some early studies have shown that e-cigarettes can reduce cigarette craving but so what?
We are beginning to get a better understanding of how e-cigarettes might reduce tobacco harm but it’s not as rosy as we first thought. By far the most successful approach is quitting by enrolling in a smoking cessation service and using licensed NRT or veranicline. Don’t be stupid and advise your smoking customers not to be stupid.
