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Nicotine Science & Policy | 10 October 2014

This meeting is the Sixth Conference of the Parties (COP-6) to the Framework Convention on Tobacco Control (FCTC). This convention is WHO’s primary instrument for addressing the health impact of tobacco use internationally. This briefing provides information on discussions about electronic cigarettes and background documentation.

1 What is this meeting for?

179 countries are parties to the Convention, notable exceptions being the United States and Switzerland and several countries where tobacco growing is economically important. They meet roughly every two years to make progress with implementation and to develop and enhance the Convention. The documentation for the meeting is here, including the agenda. Several parties will boycott the meeting in protest at Russian aggression in Ukraine.

2 Controversy at COP-6

The most controversial issue at the meeting will be agenda item 4.4 covering proposals related to ‘Electronic Nicotine Delivery Systems’ (ENDS) better known as e-cigarettes [FCTC/COP/6/10 Rev.1] and smokeless tobacco [ FCTC/COP/6/9]. This will be controversial because views in public health experts are highly polarised between those who support these products as reduced harm alternatives to smoking (pro-harm reduction faction) and those who see them as a distraction from quitting and may increase smoking (anti-harm reduction faction).

2.1 Scientists letters to WHO

Three letters have been sent by academics to WHO:

  1. 53 leading experts in the field of nicotine science and public health wrote to Margaret Chan in May 2014 arguing that e-cigarettes are part of the solution, not part of the problem [letter][context][ press coverage]
  2. A response to the first letter was organised in June 2014 by anti-tobacco and anti-harm reduction campaigner Professor Stanton Glantz and signed by 129 public health advocates [ letter].
  3. The original expert signatories provided a scientific critique of the second letter, highlighting numerous and basic flaws in their analysis and warning about misrepresenting evidence and the need to take a dispassionate approach to science [ letter ].

Prompted by a leak . The initial letter was prompted by a leak from WHO’s planning bureau for the COP-6 meeting showing that they were planning an assault on e-cigarettes at this meeting [leaked minutes][leak commentary][ FT coverage]. This showed that WHO was trying to regulate e-cigarettes as though they were tobacco products.

2.2 Scientific analysis and risk communication

WHO was clearly working towards a particular aim – the inclusion of e-cigarettes in the FCTC as though they were tobacco products. They needed a scientific basis for this and went to an academic who would give them the necessary support. This also prompted an exchange of fire – in four parts:

  1. A background paper commissioned by WHO to provide scientific input to the COP-6. 
    Grana R, Benowitz N, Glantz SA. Background Paper on E-cigarettes (Electronic Nicotine Delivery Systems): Prepared for the 7th Meeting of the WHO Study Group on Tobacco Product Regulation. December 2013

  2. A tough critique of this background paper showing that all the main conclusions should be reframed far more positively and showing that the underlying science did not support the conclusions drawn. 
    McNeill A, Etter J-F, Farsalinos K, et al. A critique of a WHO-commissioned report and associated article on electronic cigarettes.Addiction 2014. [paper] [ Press release]

  3. WHO’s paper on Electronic Nicotine Delivery Systems for COP-6 [ FCTC/COP/6/10], which argued for regulating e-cigarettes as both tobacco products and medicines, and proposed a number of policy measures, including banning vaping in all indoor public places.

  4. A thorough critique of WHO’s COP-6 paper focussed on its science and risk communication by Clive Bates of Counterfactual and former Director Action on Smoking and Health (ASH) [open letter][ report PDF]. The report highlights numerous false and alarmist presentations of e-cigarette risk by WHO, and criticises the organisation for shoddy policy-making practice.

2.3 WHO forced to change its paper

The paper on ENDS was revised without notice in early October and no detail given in the revision. The original paper was completely removed, but had been captured on the ‘web archive’. It revealed a very significant change – probably forced on the WHO by the European Union or other parties concerned about ‘scope creep’, and WHO proposing far more than justified by the evidence.

Before: FCTC/COP/6/10

52. In order to implement the suggested general regulatory objectives as well as the specific regulatory options, Parties will need to consider the available national regulatory frameworks that could best provide solid regulatory grounds. Nevertheless, it is likely that a two-pronged regulatory strategy – regulating ENDS as both a tobacco product, in accordance with the provisions of the WHO FCTC, and as a medical product – would be necessary.

After: FCTC/COP/6/10 Rev.1

52. In order to implement the suggested general regulatory objectives as well as the specific regulatory options, Parties will need to consider the available national regulatory frameworks that could best provide solid regulatory grounds

2.4 NGO alliance rejects WHO call regulation of e-cigarettes under FCTC

The Framework Convention Alliance - the alliance of health NGOs that attend the FCTC meetings and lobby delegates - produced its own policy position on 7 October [policy paper]. This is a well-balanced attempt to find middle ground between the pro- and anti-harm reduction factions.

3 Where to find good science and commentary

3.1 General assessment of e-cigarettes

Hajek P et al (2014) : EC aerosol can contain some of the toxicants present in tobacco smoke, but at levels which are much lower. Long-term health effects of EC use are unknown but compared with cigarettes, EC are likely to be much less, if at all, harmful to users or bystanders. EC are increasingly popular among smokers, but to date there is no evidence of regular use by never-smokers or by non-smoking children. EC enable some users to reduce or quit smoking.

Hajek P, Etter J-F, Benowitz N, et al. Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction 2014. [link]

3.2 Safety and risk assessment

Polosa R & Farsalinos K (2014 ): Currently available evidence indicates that electronic cigarettes are by far a less harmful alternative to smoking and significant health benefits are expected in smokers who switch from tobacco to electronic cigarettes. Research will help make electronic cigarettes more effective as smoking substitutes and will better define and further reduce residual risks from use to as low as possible, by establishing appropriate quality control and standards.

Farsalinos KE, Polosa R. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review. Ther Adv Drug Saf 2014;5:67–86. [Link]

3.3 Vapour toxicity and risks of passive vaping

Burstyn I, (2014 ) Current state of knowledge about chemistry of liquids and aerosols associated with electronic cigarettes indicates that there is no evidence that vaping produces inhalable exposures to contaminants of the aerosol that would warrant health concerns by the standards that are used to ensure safety of workplaces. However, the aerosol generated during vaping as a whole (contaminants plus declared ingredients) creates personal exposures that would justify surveillance of health among exposed persons in conjunction with investigation of means to keep any adverse health effects as low as reasonably achievable. Exposures of bystanders are likely to be orders of magnitude less, and thus pose no apparent concern.

Burstyn I. Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks,BMC Public Health 2014;14:18. doi:10.1186/1471-2458-14-18[ Link]

3.4 Quitting smoking and impact on population

Brown J et al( 2014). People attempting to quit smoking without professional help are approximately 60% more likely to report succeeding if they use e-cigarettes than if they use willpower alone or over-the-counter nicotine replacement therapies such as patches or gum

Brown J, Beard E, Kotz D, Michie S, and West R (2014) Real-world effectiveness of e-cigarettes when used to aid smoking cessation: A cross-sectional population study. Addiction109: [link]

ASH estimates that there are currently 2.1 million adults in Great Britain using electronic cigarettes, Of these, approximately 700,000 are ex-smokers while 1.3 million continue to use tobacco alongside their electronic cigarette use. Electronic cigarette use amongst never smokers remains negligible . ASH (UK) Use of electronic cigarettes in Britain, July 2014 [link]

3.5 Advice to medical professionals

West R & Brown J (2014) This brings us back to the question as to why some individuals and bodies involved in public health are so opposed to e-cigarettes. It may be a concern over how things might turn out in the future given commercial incentives, puritanical ethics, distaste for any industry profiting from a psychoactive drug, inappropriate application of a medical rather than a public health model, or even just a gut feeling that e-cigarettes are bad. Whatever the reasons, it is important that interpretation of the evidence and communication with policy makers and the public is not distorted by a priori judgements.

West R, Brown J. Electronic cigarettes: fact and faction. Br J Gen Pract 2014;64:442–3. Link