To vape or not to vape?

The Department of Health believes “further research” is needed into the long-term impact on public health from e-cigarettes.

However, the Department told the Medical Independent (MI) it does acknowledge that e-cigarettes “may have a role to play in smoking cessation or reduction”.

This response comes at a time of growing international public health debate around so-called ‘vaping’. Earlier this month, Vape Business Ireland (VBI) organised a briefing for politicians on the issue of e-cigarettes, while a recent front-page article in The New York Times questioned the US health establishment’s attitude to e-cigarettes.

In April, MI reported that the HSE’s quit smoking services had no plans to include advice or recommendations regarding e-cigarettes to the public.

<blockquote> <div> Although the studies are small in number, there is emerging evidence that e-cigs can help smokers quit and there is no evidence of significant harm

</div> </blockquote>

“The HSE cannot recommend e-cigarettes as a smoking cessation aid, as they are not currently regulated or approved in Ireland for that purpose,” a HSE spokesperson told MI in April.

“E-cigarettes are relatively new and their use is the subject of ongoing international research to determine their safety and efficacy as a smoking cessation aid. However, for those unable or unwilling to stop using nicotine, using e-cigarettes (also known as ‘vaping’) is generally regarded as less harmful than smoking tobacco.

“We recommend that smokers trying to quit smoking by using e-cigarettes do so in combination with approved evidence-based methods/supports and seek advice from HSE quit services.”

The HSE had not replied to MI by our deadline last week when we asked whether there had been any changes to this stated position from April.

<div style=”background: #e8edf0; padding: 10px 15px; margin-bottom: 15px;”> <h3>E-cigarettes usage in Ireland</h3>

14 per cent of the population have tried e-cigarettes at some point, however only 3 per cent still use them.

45 per cent of smokers, 13 per cent of ex-smokers and 1 per cent of those who have never smoked have tried e-cigarettes at some point.

6 per cent of ex-smokers currently use e-cigarettes and a further 7 per cent have previously used them.

Of the 10 per cent who successfully quit smoking in the past 12 months, almost half (48 per cent) did so through willpower alone. Almost a third (32 per cent) used e-cigarettes as a quitting aid.

*All figures from the most recent Healthy Ireland Survey

</div>

The Department and Minister for Health have also been reluctant to provide full support for e-cigarettes as a tool to help cease smoking.

“E-cigarettes are a relatively new product category and their market share is growing,” a spokesperson for the Department told MI last week.

“While they may have a role to play in smoking cessation or reduction, their long-term effects on public health are not yet known and further research is required. In order for such products to claim to be used in or assist in smoking cessation, they would require marketing authorisation from the Health Products Regulatory Authority to be regarded as medicinal products.

“Current evidence-based means of quitting smoking include behavioural support and pharmacotherapies. The HSE provides and promotes these safe and evidence-based services, supports and aids to help people to quit. The Department recommends that those wishing to give up smoking use the HSE’s cessation services as the first port of call.

“The Department will continue to monitor evidence on the potential harms and benefits of these products, so as to inform decisions around any future additional regulation in this area.”

<h3>Advice </h3>

The reluctance of the HSE and the Department to fully embrace vaping in their smoking cessation campaigns is reflected among the attitudes of the charity sector.

The Irish Cancer Society is one of the leading bodies involved in the campaign against tobacco smoking in Ireland. It told MI that it continues to monitor developments when it comes to the role vaping may play.

“The Irish Cancer Society acknowledges that e-cigarettes are less harmful than tobacco, however we cannot currently recommend them for use as a smoking cessation device until further research is carried out into the long-term health implications,” a Society spokesperson told MI.

“Further work is required to measure the long-term health effects and patterns of e-cigarette use in this quickly-evolving field and we continue to monitor any developments relating to the potential harms and potential benefits of e-cigarettes.”

Yet while there is no official Irish advice recommending e-cigarettes as an aid to quitting smoking, information from the Government’s own Healthy Ireland Survey 2016 survey shows that this is what many smokers here are actually doing.

The most recent Healthy Ireland results published last month showed that a significant number of those who have recently ceased smoking have used e-cigarettes.

The survey found that of the respondents who successfully quit smoking in the past 12 months, almost half (48 per cent) did so through willpower alone. However, almost a third (32 per cent) used e-cigarettes as a quitting aid.

Some addiction experts believe that potentially, vaping has a significant role to play in pulling people away from tobacco.

<blockquote> <div> …everything I know about tobacco control suggests that this isn’t going to be good for tobacco control

</div> </blockquote>

“Not only is vaping an alternative, with 99 per cent of vapers being ex-smokers, research in the UK has estimated vaping to be 95 per cent less harmful than combustible tobacco products,” said Dublin-based GP Dr Garrett McGovern.

Dr McGovern specialises in alcohol and substance abuse and he was speaking to politicians at the recent political briefing organised by VPI (see panel on p16).

Dr Garrett McGovern

He believes that vaping products are not a gateway to smoking, but can be an alternative for those looking to quit smoking and that this should be borne in mind by regulators.

“There has been no evidence to suggest that vaping is a gateway to smoking; the scientific facts must not be disregarded.

“Therefore, vaping products should not be blocked by policy-makers from offering an alternative to smoking.”

Speaking to MI, Dr McGovern said he is not sure why public health has not universally embraced e-cigarettes.

“But possibly [it’s] an abstinence ideology; we encounter the same problem with methadone treatment,” he comments.

“It is certainly not based on evidence, which although the studies are small in number, there is emerging evidence that e-cigs can help smokers quit and there is no evidence of significant harm.”

Dr McGovern highlights an August 2015 expert independent evidence review published by Public Health England (PHE), which concludes that e-cigarettes are “significantly less harmful to health than tobacco and have the potential to help smokers quit smoking”. Also, a Royal College of Physicians (RCP) survey from England in April this year made similar conclusions.

“As these highlight, while there is a possibility of harm emerging in the years to come — the current model of e-cigs are only around since 2003 — it cannot be realistically compared to tobacco, whose harms are well established,” contends Dr McGovern.

“If young people use e-cigarettes as an alternative to smoking, then that can only be a good thing. I am not advocating anyone aged under 18 uses e-cigs, but they are much safer than tobacco.”

A recent front-page article in The New York Times questioned whether the American public health establishment’s cool stance towards e-cigarettes was effective.

“American public health experts, led by the Centres for Disease Control (CDC) and Prevention, have long been suspicious of e-cigarettes,” reads the article.

“The possible risks of vaping are vast, officials warn, including the potential to open a dangerous new door to addiction for youth. Scientists will not know the full effect for years, so for now, they caution, be wary.”

While US health bodies have been slow to warm to vaping, there have been varying voices within the UK.

In April this year, the RCP in London released a report titled Nicotine without smoke: Tobacco harm reduction.

According to the RCP, the report “shows that, for all the potential risks involved, harm reduction has huge potential to prevent death and disability from tobacco use and to hasten our progress to a tobacco-free society”.

The report finds that “e-cigarettes appear to be effective when used by smokers as an aid to quitting smoking”, but that “e-cigarettes are not currently made to medicines standards and are probably more hazardous than nicotine replacement therapy (NRT)”.

“However, the hazard to health arising from long-term vapour inhalation from the e-cigarettes available today is unlikely to exceed 5 per cent of the harm from smoking tobacco.

“However, in the interests of public health, it is important to promote the use of e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK.”

<h3>No political leadership on vaping </h3>

The role of regulation and legislation around vaping has become an issue in Ireland in recent months.

“In the absence of regulation, the quality and safety of e-cigarettes varies by brand,” an Irish Cancer Society spokesperson told MI.

“We believe that the introduction of the Tobacco Products Directive (TPD) and the measures contained relating to e-cigarettes will serve to improve safety and efficacy of these products in an industry that has, to date, been unregulated.

“The new regulations restrict advertising, set out safety and quality requirements for electronic cigarettes and refill containers, introduce labelling guidelines and health warnings, and include requirements for notification to the HSE of any products intended for the Irish market, among others items. The restrictions on advertising and sponsorship contained as part of the TPD will, we hope, help prevent the ‘renormalisation’ of smoking.”

Those within the industry also say they want regulation.

“Vape Business Ireland (VPI) are looking for regulation that is evidence-based and sensible,” a spokesperson for VBI tells MI.

“The Tobacco Products Directive currently regulates vaping products in Ireland. While we disagree with the fact that a consumer electronic product that contains no tobacco being lumped in with tobacco-containing products, we do agree that the sector should be regulated.

“We have a lot of evidence from the health agencies in the UK stating that they are 95 per cent less harmful (PHE) and not a gateway to smoking but unfortunately, our own Department of Health will not fully acknowledge the potential benefits vaping could have for those looking for an alternative to smoking but have so far refused to do any of their own research, apart from a few questions in the Healthy Ireland survey.

“There is also a huge lack of clarity from the health charities here on what their position is and unfortunately, it is far different to their counterparts in the UK.”

VPI hosted a recent briefing for politicians regarding issues around vaping, however, it admitted the turnout was disappointing.

“Our event allowed for an open debate between the medical profession, the business and the lobbying sides of the sector,” said the VPI spokesperson.

“Unfortunately, the turnout from our politicians was poor and as Dr [Garrett] McGovern said, it is clear that there is no interest among the Government and politicians to see vaping products as the future for ex-smokers.

“Healthy Ireland 2016 quotes that of those who have successfully quit smoking, 32 per cent used vaping products, which is incredible. Yet www.quit.ie, the HSE or Department of Health do not give consumers or ex-smokers any advice or guidance on these products. VBI believes this is a huge shame.”

However, there are some political voices who have been more positive about vaping. Speaking in the Dáil last month, Independent TD Joan Collins related her own personal smoking experience.

“I tried to stop smoking on eight occasions because I knew it did terrible harm to my body from a health point of view,” said Deputy Collins.

“It always proved difficult and I ended up going on and off the cigarettes again and again. I am vaping at the moment.

“I think the Government should be careful not to make it more difficult for people to access vaping products because they have played a role in my campaign to stop smoking and move onto alternatives with the intention of moving off them over a period of time.”

</div> <h3>Cautious</h3>

There are other voices within public health that are more cautious about vaping.

Prof Luke Clancy, Director General of the Research Institute for a Tobacco Free Society (RIFTFS), admits that he is “worried about them [e-cigarettes], coming from a tobacco control point of view”.

“First thing is that they were seen to be advocated as a treatment to help people stop smoking — as a smoking cessation aid,” Prof Clancy, a consultant respiratory physician, told MI. “There are two randomised, control trials, both are equivocal and the best they showed [is] they might be as good as NRT. So as a smoking cessation aid, they are very limited. It’s another form of nicotine.

“They are very popular — that is the big thing in their favour. They have not been shown to be better than NRT.”

Prof Luke Clancy

Prof Clancy adds that the “harm reduction” claims made for e-cigarettes are dubious, in his opinion. He points out that there has been much progress made in the campaign against smoking and e-cigarettes may not be helpful in this.

“It is probably true that they are less harmful than cigarettes. But cigarettes are the most dangerous product freely available,” says Prof Clancy.

“We are always saying that if cigarettes tried to come on the market today [for the first time], they would be stopped. Yet here is an addictive product that some people would like to encourage. So that jars because it’s not consistent.

“The other thing is that we are doing fairly well in tobacco control. For instance, we just published a report on children smoking. Twenty years ago, nearly 45 per cent of kids were smoking at 17. Today, it’s 6 per cent daily, 13 per cent occasionally. So there has been a dramatic reduction in smoking.

“So do you think these e-cigarettes will help this, when we know that about 20-25 per cent of young people at 17 have tried e-cigarettes and we know they are addictive? Do we really think that it is going to reduce smoking in the long term? I can’t square it.

“I’m not infallible [but] everything I know about tobacco control suggests that this isn’t going to be good for tobacco control.”

But Prof Clancy concedes that e-cigarettes are popular and a reality that the public health system cannot ignore.

“They are addictive. Even in themselves, is it a good idea that people become addicted to nicotine?

“It cannot be good for tobacco control. They may have a role in the treatment of tobacco dependency — if so, they need to show that and they need to be used within a programme.

“They are very popular [but] I don’t see it as a great opportunity, but I do think it’s a reality that has to be dealt with.”

Dr Des Cox is the Chair of the Policy Group on Tobacco at the RCPI, which said that it will be considering the most recent medical evidence on e-cigarettes.

“While electronic cigarettes and vaping devices are likely safer for the individual user with regard to tobacco-related morbidity and mortality, they are not risk-free products and their potential as a cessation aid is still unclear,” Dr Cox told MI.

“There is also concern that they may re-normalise smoking.

“In 2016, the Policy Group on Tobacco will consider the most recent evidence on e-cigarettes with regard to efficacy and safety.”

Minister of State for Health Promotion Marcella Corcoran Kennedy recently told the Dáil that “my Department will continue to monitor existing and emerging evidence on the potential harms and potential benefits of vaping, so as to inform any future decisions in this area”.

Mixed signals are also emerging in terms of sales of e-cigarettes.

Earlier this month, The New York Times reported that “a decade after electronic cigarettes were introduced in the United States, use has flattened, sales have slowed and, this fall, NJoy, once one of the country’s biggest e-cigarette manufacturers, filed for bankruptcy”.

Trends often start in the US, and MI spoke to the manager of a very busy Spar store in Dublin city centre who also noted that sales of e-cigarettes have fallen over the last year. However, he speculated that part of this might be to do with increasing online sales and the opening of specialised vaping cafes.

So time will tell if e-cigarettes are here to stay, or are just another passing fad.

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