Evidence and E-Cigarettes: Explaining English Exceptionalism

What should health professionals advise about e-cigarettes? In this issue of AJPH, Fairchild et al. (p. 1000) compare reports offering two very different perspectives. One is by Public Health England (PHE), the body charged with protecting the health of the population, which has promoted e-cigarettes, or vaping, enthusiastically as a means to reduce the harm associated with smoking (for additional reading, see the Appendix, available as a supplement to the online version of this article at http://www.ajph.org). The other, by the US National Academies of Science, Engineering, and Medicine (NASEM), takes a much more cautious view, noting the large gaps in the available research as well as the warning signs in studies that have been undertaken. Fairchild et al. attributed this difference primarily to PHE’s focus on the potential benefits to existing smokers in England, whereas the US report emphasizes the protection of nonsmokers, including children, who may be attracted to e-cigarettes and thus at risk for nicotine addiction, including, potentially, cigarette smoking. They also point to other differences, such as the priority given to randomized control trials in the NASEM report, whereas the PHE report questions their value, seeing them as inconsistent with the real-life situation.

The situation in which two groups assessing the same evidence reach differing conclusions is not unique and can be attributed to differing weights placed on particular issues. For example, perspectives on genetically modified food may differ depending on whether one views it as an issue of consumer safety, biodiversity, or the power of multinational producers over small farmers. But is it simply a question of different perspectives that explains the markedly divergent conclusions about e-cigarettes? To answer this question, it is necessary to recognize, as Fairchild et al. note, that England really is quite exceptional in its approach to e-cigarettes. Thus, another report, written by the Australian Commonwealth Scientific and Industrial Research Organization and stretching to 394 pages,¹ reaches conclusions that are broadly similar to those of the NASEM Report. So does a statement by the Forum of International Respiratory Societies, bringing together nine of the leading professional organizations worldwide working on respiratory health.²

The European Public Health Association, representing 40 national associations of public health, is similarly concerned, as are the European Commission, the World Health Organization, and many others (see Appendix). Thus, rather than comparing just two reports, surely the more important question is why PHE, along with some other English organizations, such as the Royal College of Physicians and the English advocacy organization Action on Smoking and Health, takes a view that is so much at odds with those in the rest of the world?

DIFFERENT PROFESSIONAL PERSPECTIVES

It does seem that the backgrounds of those assessing the evidence matters. Some of the strongest advocates of e-cigarettes in England are respiratory physicians (although, as noted, the leading respiratory organizations do not share their views). They are confronted daily with individuals addicted to nicotine who seem unable to quit smoking. They hear compelling stories from individuals who have found e-cigarettes an aid to quitting. Yet many studies find that the net result is a reduction in quitting, whereas dual users, who are typically the majority, are more likely to transition to exclusive cigarette use than to either sole e-cigarette use or complete abstinence.³ They may also believe in the “hardening” hypothesis, whereby it is thought that as smoking rates decline, those few smokers who remain are especially resistant to quitting, although the most recent, thorough review shows that evidence does not support this.⁴ Other strong supporters have worked with drug users and are familiar with methadone and needle exchanges being used as established means of harm reduction. Yet the approach advocated by e-cigarette enthusiasts lacks some of the core elements employed in the narcotics field (see Appendix).

Those favoring a much more cautious approach to e-cigarettes are, by contrast, drawn primarily from the public health community, which focuses on the overall population impact, anticipating the ability of e-cigarettes to recruit a new generation of smokers; pediatricians, who share those concerns; and cardiologists, who recognize the growing evidence linking components of e-cigarette vapor to endothelial damage in particular.

LACK OF HARD EVIDENCE FOR HARMS

It seems necessary to look beyond these differences in emphasis. PHE was one of the first organizations to support e-cigarettes. It has actively promulgated the claim that they are 95% safer than conventional cigarettes. Crucially, that claim is derived not from empirical evidence but from a meeting attended by 12 people, many who had previously expressed support for e-cigarettes. The report, often referred to as the “Nutt report” after its lead author, provided this remarkably precise and memorable figure even though their article conceded, “A limitation of this study is the lack of hard evidence for the harms of most products on most of the criteria.”^5(p224) Despite this most fundamental of caveats, a senior PHE official told an Australian parliamentary inquiry, “We are very clear that this is just one of the figures that we have used, and there are plenty more. We say what really matters is the evidence underlying this figure came from the Nutt report.”^{6[emphasis added]} To complicate matters further, there are important questions about the funding of the meeting, specifically any role of the tobacco industry, that are yet to be answered satisfactorily.⁷

Of course, considering how little time has elapsed since e-cigarettes entered widespread use, it is impossible to put a precise figure on harm, and the emerging evidence indicates that it is inappropriate to view them as a safer form of cigarette, as both types contain substances not found in the other, ensuring that dual users will have the worst of both worlds. But, because of the prominence of this claim, now afforded extensive visibility via e-cigarette industry promotion, it has been hard to retreat from it.

This is an example of what is termed “escalation of commitment” or, by economists and behavioral scientists, “sunk cost fallacy” (see Appendix). Once embarked on a course of action or line or argument, it is difficult to extract oneself. It leads to a situation in which evidence that supports the position being held is promoted, whereas that which challenges it is dismissed. Thus, even though Juul e-cigarettes—which have come to dominate the US market in just three years—are only now entering the UK market—with evidence already of an increase in adolescent e-cigarette use—we are to believe that the situation is somehow completely different from that in the United States, where adolescent vaping has assumed epidemic proportions. Considering a common language and the strong cultural links between the two countries, the idea that the powerful provaping imagery on the Internet will somehow disperse in a puff of smoke on its journey across the Atlantic seems, to say the least, implausible. So, as we seek to explain this example of English exceptionalism, the answer may lie in the growing literature on cognitive biases.