Gerry Stimson and Paddy Costall | 19 January 2014
We struggle to understand why so many public health colleagues are anti-pathetic to electronic cigarettes. The uptake of e-cigarettes has been a consumer-led public health revolution. At no cost to the NHS, and without government or public health support and promotion, thousands of people have found that e-cigarettes help them switch from smoking. Using e-cigarettes is a classic harm reduction approach – a safer product and delivery device for those who do not want to give up nicotine. It fits two public health principles – the first is to reduce harms to populations and the second is to engage and work with populations in their endeavour to lead healthier lives.
Many public health experts have in the past been strong supporters of harm reduction for illicit drugs. Indeed it was brave public health experts in a number of UK cities who took the reputational risk of promoting needle exchange and methadone treatment, in order to avert the spread of HIV infection. They took this courageous decision at a time when government was strongly “anti-drugs”. This pragmatic approach was met with some reluctance by the Thatcher government, but under the leadership of Norman Fowler - the then Minister for Health – harm reduction and “safer drug use” chimed with the other part of that AIDS response – safer sex. Odd then that some of those same public health leaders, and their successors, are not joining the ranks of those who support tobacco harm reduction.
Whenever the public health experts and organisations pronounce on e-cigarettes, we hear a recurrent refrain: e-cigarettes re-normalise smoking, they are a “gateway to nicotine addiction and smoking”, “the tobacco industry is involved”, “marketing of flavours is targeted at recruiting children”, and the promotion of e-cigarettes “glamorises nicotine” in a way that smoking adverts glamorised smoking. This is accompanied by the reiteration of dubious claims – that “we do not know what is in them”, that “children are using them”, and uncertainties about their effectiveness as quitting devices. This is often accompanied by advice to patients and consumers to use the supposed effective treatments - ie NRT and varenicline.
Further obstacles are created to discourage use. For example, Public Health Wales has advised that their use in public enclosed places be prohibited in the same way as tobacco cigarettes are. All public health directors in Scotland have pronounced that they should not be used on NHS premises. Local public health teams likewise argue for bans. Fiona Godlee, editor of the British Medical Journal, has applauded the Bloomberg’s ban on e-cigarettes in public enclosed spaces in New York.
This reticence to embrace e-cigarettes has a number of drivers. First there is the suspicion of many public health experts regarding working with any industry to achieve public health gains. Some public health experts had bad experiences working on Andrew Lansley’s “responsibility deal” which attempted to bring together public health and food and beverage producers. Second is the long-standing anti-tobacco and anti-smoker mentality of public health and tobacco control organisations: for so long driven by being ‘anti’ it’s hard for some to switch into a positive mode. Third is the reluctance of public health and tobacco control organisations to engage with smokers, which spins over to reluctance and inability to conceive of engagement with vapers. Fourth, we think there is a bit of suspicion and jealousy because the e-cigarette movement did not emanate from medicine or public health, hence public health never felt it had “ownership” of the initiative. Fifth, it is not that the public health experts are lazy, but they have a large number of health issues to deal with, hence the tendency to adopt “narratives” from public health thought leaders. How else to understand how the same untested and unchallenged phrases crop up in different pronouncements?
This matters. Most of the attention regarding the future of electronic cigareetes has focussed on the European legislative process. But, despite what happens with the Tobacco Products Directive in Brussels, UK public health directors help set the tone for local public health responses. They are the ‘authoritative voice’ to which local policy makers turn. Hence a public health voice discouraging the use of electronic cigarettes, or against vaping in public places, is likely to be picked up and acted upon by local municipal authorities, and others with responsibility for public premises such as transport operators, employers, and the hospitality sector (venues, pubs, clubs).
Whatever happens in Brussels regarding “regulation” of the industry, e-cigarette use will also be determined by locally determined “rules”: hence it is essential that local public health doctors are sensitised to issues concerning electronic cigarettes, are made aware of the evidence, and don’t come up with ill-considered anti-vaping advice.
Gerry Stimson is also Emeritus Professor, Imperial College London, and Visiting Professor, London School of Hygiene and Tropical Medicine
A version of this blog was originally published by Save e-cigs
What can you do? In England public health directors are employed by and responsible to local authorities. This means they are responsible to your local councillors. Why not help your local authority be the first to support vaping?
Each local authority in England has its own Health and Well-being Board, which determines policy and priorities at a local level, within the overall framework set by Public Health England. Contact details and information on policies can be found on the local authorities’ websites.
In England, overall guidance for public health directors is the responsibility of Public Health England. Public Health England has yet to pronounce on e-cigarettes. The Director of Health and Wellbeing is Dr Kevin Fenton https://www.gov.uk/government/people/kevin-fenton. He has tweeted concerns about e-cigarettes @ProfKevinFenton.
In Scotland, the Chief Executive of NHS Health Scotland is Gerry McLaughlin and you can find the board members here: http://www.healthscotland.com/about/board/members.aspx. At a local level policy and priorities are the responsibility of public health directors within the local health boards. Details of these can be found at http://www.show.scot.nhs.uk/introduction.aspx