UK Faculty of Public Health Policy Statement on Electronic
Cigarettes
About the Faculty of Public
Health
The
Faculty of Public Health is the standard setting body for specialists in public
health in the United Kingdom. The
Faculty of Public Health is a joint faculty of the three Royal Colleges of
Physicians of the United Kingdom (London, Edinburgh and Glasgow) and also a
member of the World Federation of Public Health Associations. The Faculty of
Public Health is an independently constituted body with its own
membership and governance structure.
The Faculty of Public Health is the professional home for more than 3,300
professionals working in public health. Our members come from a diverse range
of professional backgrounds (including clinical, academic, policy) and are
employed in a variety of settings, usually working at a strategic or specialist
level. The Faculty of Public Health is a
strategic organisation and, as such, works collaboratively, drawing on the
specialist skills, knowledge and experience of our members as well as building
relationships with a wide range of external organisations.
Introduction
The
Faculty of Public Health strongly believes that the
advertising and promotion of electronic cigarettes to non-smokers, including
children, can and should be prevented. In light of overwhelming evidence that voluntary codes on marketing of
tobacco and alcohol products have failed to protect young people from such
advertising we therefore believe an outright ban on marketing of electronic
cigarettes is preferable.
We share the concerns of Dr Haik Nikogosian of the WHO
Framework Convention on Tobacco Control Secretariat, who cautions that
electronic cigarettes “could result in a new wave of the tobacco epidemic.”[1]
We are alarmed by the rapid growth in advertising for electronic cigarettes
from multinational tobacco companies. We also recognise the “fundamental and irreconcilable conflict of interest
between the tobacco industry’s interests and public health policy interests”.[2]
The Faculty of Public Health understands that electronic
cigarettes are likely to be less hazardous than smoking. In view of the higher
levels of addiction among the most disadvantaged smokers, access to pure
nicotine products as an alternative to smoking may be an important means of
tackling health inequalities and helping communities manage very high levels of
addiction and reducing risk.
However, we view the safeguards highlighted below as an essential
pre-requisite to that access. We believe additional safeguards are required to
ensure that electronic cigarettes are as effective as possible, deliver
nicotine in as safe as possible a way and are manufactured to a consistent
quality.
The Faculty of Public Health is one of 129 signatories to a letter
to Dr Margaret Chan, Director General of the World Health Organisation
outlining our concerns.
The Faculty of Public Health also responded
to the recent Committee of Advertising Practice and Broadcast Committee of
Advertising Practice consultation on the marketing of electronic cigarettes.
The Faculty of
Public Health has major concerns, which together make a powerful case for the
regulation currently proposed by WHO. These four major concerns are:
- The tobacco industry is using
electronic cigarettes to promote traditional cigarettes and gain access to
policy makers
- Electronic cigarettes may be a
‘gateway’ to smoking among young people and non-smokers
- The efficacy of electronic cigarettes
as smoking cessation aids remains uncertain
- The safety of electronic cigarettes has
not been scientifically demonstrated
The evidence underpinning these concerns is
summarised below, followed by our Recommendations.
1.
The tobacco industry is
using electronic cigarettes to promote traditional cigarettes and gain access
to policy makers
The Faculty of Public Health is deeply concerned by the aggressive marketing and promotion of
electronic cigarettes to young people.
We note with grave concern the recent report
by a group of US Senators [3]
that concludes that, in the USA, manufacturers are:
- promoting
products through sponsorship of youth oriented sports events
- using
flavours designed to appeal to youth, and;
- using
celebrity spokespersons that appeal to youth.
The Faculty of Public Health also draws
attention to a separate recent study published in the American Journal of
Preventative Medicine, which found that electronic
cigarettes are being aggressively marketed with health claims and smoking
cessation messages that are not supported by the available evidence. The
study concludes that “implied and overt health claims, the presence of doctors
on websites, celebrity endorsements, and the use of characterizing flavours
should be prohibited.”[4]
The Faculty of Public Health draws attention to a website compiled
by a US Senate Committee that compares imagery employed by the electronic cigarette
manufacturers now and tobacco companies in the past, and which shows that many
images are virtually identical, except that the clothing of the models and
accessories used are more modern.[5]
The Faculty of Public Health contends that many of these images can be
considered to be seeking to renormalize and re-glamourise the imagery of
smoking, especially as many promote products that are almost indistinguishable
from real cigarettes.
Similar
concerns are raised by a recent review of electronic cigarette marketing in the
UK.[6]
The Faculty of Public Health is confident that the tobacco industry is
explicitly using its ability to advertise electronic cigarettes as a covert
means of promoting its main product, the traditional cigarette. This is
particularly pertinent at a time when the last route available for the tobacco
industry to market its products, the packet, looks likely to be closed.
The Faculty of Public Health is also concerned, given overwhelming
evidence of the tobacco industry’s efforts to undermine public health policies,
that the tobacco industry will use reduced risk products as a means of
presenting itself as a partner in policy making [7]
thus undermining Article 5.3 of the Framework Convention on Tobacco Control.
2.
Electronic cigarettes may be
a ‘gateway’ to smoking among young people and non-smokers
In the US, which is further ahead on the curve of electronic cigarette
use, the Centers for Disease Control and Prevention found that from 2011 to
2012 current electronic cigarette use increased significantly among middle
school and high school students [8] (from 0.6% to 1.1%, and from 1.5% to 2.8% respectively). No longitudinal studies UK have examined
whether electronic cigarettes serve as ‘gateways’ to future tobacco use. These
data are urgently required. Until then, the precautionary principle suggests
that it would be rash to dismiss the worrying trends in US children.
It is therefore entirely possible that the
situation in the UK could change. Particularly given the high levels of
promotion and how advertising and promotion of electronic cigarettes seeks to
glamorise the use of these products and promote their use to young people.
Making a clear distinction between children and adults is therefore critical,
and rigorous and ongoing monitoring and evaluation of this risk are necessary.
The logic points towards a complete ban on marketing to adults and children.
While research carried out for Action on
Smoking and Health suggests that there is no current compelling evidence to
suggest that young people are using electronic cigarettes as a ‘gateway’ to
smoking, this situation could change rapidly. The latest data from Action on
Smoking and Health, a March 2013 survey of children 11-18 years old
showed that of 1428 children who had heard of electronic cigarettes, 1% had
tried them but none reported continued use. However, these data are now old,
and a new survey is urgently indicated.
3. The efficacy of electronic cigarettes as smoking
cessation aids remains uncertain
There
is as yet no evidence from clinical controlled trials that electronic
cigarettes are any more effective than existing means of nicotine delivery,
with the one trial that has been conducted showing no significant difference. [9]
The
most promising evidence comes from the cross-sectional Toolkit study suggested
that smokers in England intending to quit who used electronic cigarettes in
their last quit attempt were more likely to quit than those using over the
counter nicotine replacement. [10] However, this was cross-sectional data, not a
randomised study, and the results must therefore be viewed with caution. It is
not possible to assess effectiveness with such studies, and the
counter-intuitive finding that those using over the counter nicotine were less
likely to quit than those who were unassisted raises serious questions about
the interpretation of these findings.
Moreover,
no comparison was made with those using full behavioural support and NHS
prescribed nicotine replacement therapy, which is known to be the most
effective means of stopping.
The Toolkit study is good news for smokers
who want to stop and do not want to use NHS support services. [11]
However, while the study emphasises that over the
counter nicotine replacement therapy or electronic cigarettes are much less
effective than supported attempts to quit, it tells
us nothing about smokers who are not attempting to quit who are dual users.
The American evidence for dual usage suggests
the tobacco usage is prolonged and smokers may not attempt to quit. They are
able to use electronic cigarettes when they would otherwise be in public places
where smoking is banned and therefore they are not getting a harm reduction
effect at all. The
implication for population health as a whole therefore would not lead us to an
overall reduction in smoking. [12]
The
Faculty of Public Health underscores the position on this issue as presented
within the recent letter to the WHO to which we are a signatory. In particular,
it is significant that most electronic cigarette users are ‘dual users’ who continue
to smoke cigarettes. Reviews of evidence about reducing smoking (instead of
quitting) show that dual users are unlikely to see any health benefit in terms
of cardiovascular disease. Population studies of all smokers consistently show
that smokers who use electronic cigarettes are less likely to stop
smoking.
Furthermore,
the decline in traditional cigarette use may be attributable to a variety of
factors unrelated to uptake of electronic cigarette use, including the impact
of austerity and economic destabilisation. Smoking has fallen more rapidly in
several countries that have experienced austerity but where electronic
cigarettes are not widely available. Indeed, smoking rates smoking rates also declined abruptly during the Cuban
economic crisis. These rates then recovered during
economic recovery. [13]
Evidence of similar trends in alcohol consumption is also clearly
documented. [14]
The Faculty of Public Health is particularly concerned about the potential for
misleading messages that may lead those considering quitting to instead simply
reducing consumption of normal cigarettes while simultaneously using electronic
cigarettes, as is happening with adolescents in Korea.[15]
This assumes a linear reduction in risk with reduced smoking. This is NOT the
case, especially for heart disease, where a small amount of exposure to
cigarette smoke greatly increases risk. This became clear with falls in heart
attacks in many countries following smoking bans in public places.
4.
The safety of electronic
cigarettes has not been scientifically demonstrated
The Faculty of Public Health is
concerned that the safety of electronic cigarettes has not been scientifically
demonstrated and that they present potential and currently undetermined risks
for health at individual and population level especially if use occurs among
current non-smokers.
The
Faculty of Public Health draws attention to concerns raised by the World Health
Organization (WHO) that safety of electronic cigarettes has not been
scientifically demonstrated and that the potential risks they pose for the
health of users remain undetermined. We note
the WHO’S finding, coupled with evidence from the tobacco industry’s own
documents and recent research, that scientific testing indicates the products
vary widely in the amount of nicotine and other, potentially hazardous, chemicals they deliver, with evidence
demonstrating that in some products levels of carcinogens can reach those
present in cigarette smoke. [16]
While
there is good evidence of their considerably lower toxicity relative to
cigarette smoking, and therefore current smokers who cannot or do not wish to
quit would be better off switching entirely to electronic cigarettes, the
chemicals used in electronic cigarettes have not been fully disclosed, and
there are no adequate data on their emissions or long term health impacts. [17] We are concerned,
therefore, both by potential use among non-smokers and by indoor exposure to
potentially toxic substances emitted by electronic cigarettes that may cause
harm to health.
These products, when containing nicotine – can pose a risk of nicotine
poisoning, a risk that is increased by the way that many are packaged and
flavoured in ways that are attractive to children. If a child of 30 kilos of
weight swallows the contents of a nicotine cartridge of 24 mg this could cause
acute nicotine poisoning with potentially fatal consequences.
Nicotine, whether inhaled, ingested or in direct contact with the skin,
can be particularly hazardous to the health and safety of certain populations –
such as children, young people, pregnant women, breastfeeding mothers, people
with heart conditions and older people. [18]
The Faculty of Public Health is also deeply concerned that nicotine exposure
has adverse effects on fetal growth and development, including fetal brain
development, even though these risks are much less than the considerable risks
of continuing to smoke during pregnancy.
When
electronic cigarettes are used as cessations aids, they are intended to deliver
nicotine directly to the lungs. The biological mechanism by which smoking
cessation might be achieved by delivery of nicotine to the lungs and its
effects are unknown. There is no evidence that delivery to the lung is safe.
Therefore, independently of the effects of nicotine, it is of global importance
to study lung delivery scientifically. The dose of delivered nicotine is also
unknown. It is suspected that the delivered dose varies notably by product,
given that they contain nicotine in various quantities and concentrations.[19]
It
is also of great significance that nicotine is a highly addictive substance and
the Faculty of Public Health is concerned at
the prospect of non-smokers, in particular young people, developing addiction
to electronic cigarettes.
Recommendations
The Faculty of
Public Health therefore strongly believes that the ideal regulatory framework
should prevent initiation among youth and other non-tobacco users and protect
bystanders.
It should also
maximise product safety and enable current smokers who would or cannot
otherwise quit to move to electronic cigarettes.
The Faculty of Public Health recognises that it is difficult for a single
regulatory framework to achieve all these aims. We note that regulations
already agreed under the 2014 EU Tobacco Products Directive will come into force in 2016. These
stipulate that electronic cigarettes can either be regulated as medicines (and
then subject to the same marketing controls as medicines) or as consumer
products (and then subject to the same marketing controls as tobacco). The
Faculty of Public Health powerfully supports this regulatory approach, and, in
particular for electronic cigarettes to be subject to the same marketing
controls as tobacco. The UK Government is permitted to implement the Tobacco
Products Directive without delay and we strongly encourage it to do so.
The Faculty of Public
Health is concerned about the high levels of marketing and exposure (e.g.
through use in public places) that young people will be exposed to between now
and 2016. As such it also recommends that:
- urgent implementation of controls on marketing and
use in public places in line with Articles 8 and 13 of
the WHO Framework Convention on Tobacco Control[20]
- Marketing controls should extend to bans
on the sponsorship of sports clubs or sporting events, product placement,
use of flavours designed to appeal to youth and celebrity spokespersons
- All products should be required to
clearly indicate the addictive nature of nicotine and encourage smoking
cessation by providing links to the NHS Smokefree website
- Outlets
selling electronic cigarettes provide information on the dangers of
smoking and encouraging cessation
- All electronic cigarettes, including unlicensed products, should be
subject to the same marketing controls as tobacco products so that they
cannot be marketed or advertised
- The
regulatory framework should aim to prevent initiation among youth and
other non-tobacco users, protect bystanders, regulate marketing and
prohibit unsubstantiated claims
- This
regulatory framework should require manufacturers to present safety and
efficacy data
- A health authority should
assess manufacturer’s claims as it would for any medicinal product, impose
health warnings as appropriate, and require ingredient and safety data
disclosure
- Independent data on both the exclusive and dual use of
electronic cigarettes by socioeconomic status should be collected
In light of evidence showing how
the tobacco industry intends to misuse its claimed interest in harm reduction,
the Faculty of Public Health stresses that full weight should be accorded to
Article 5.3 of the FCTC.
- Developments should be closely monitored and
independent data on use of electronic cigarettes by socioeconomic status
should be collected
Regulation
should ensure that:
- products are consistent in quality and
deliver nicotine as effectively and safely as possible;
- no advertising and marketing can target
children and young people or other non-smokers (including through
sponsorship of sporting events, product placement, use of flavours
designed to appeal to youth, or use of celebrity spokespersons);
- no advertising or use (for example, in
public places) can ‘renormalise’ or ‘re-glamourise’ smoking and undermine
smoking prevention policies;
- all products clearly indicate the
addictive nature of nicotine and encourage smoking cessation by providing
links to the NHS Smokefree website;
- no advertising or marketing is based
misleading or unsubstantiated health claims;
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