Not for the first time, I am afraid that I must disagree with many of the points that Newton and Dockrell make. They challenge my argument that England is an outlier with regard to e-cigarettes and suggest that it is in the vanguard of a global movement. Yet San Francisco, California, has banned sales of e-cigarettes, and the recently appointed acting commissioner of the US Food and Drug Administration has said that “we are working as hard and expeditiously as possible to protect the public’s health from the harms associated with e-cigarette use” (http://bit.ly/31TN8zO). Elsewhere, Hong Kong and Singapore have joined the growing list of countries, including Brazil, Egypt, Thailand, and Uruguay, where authorities, having reviewed the evidence, have banned or severely restricted e-cigarettes. Within Europe, the situation in England, where advertisements feature prominently on billboards and buses and where Public Health England (PHE) actively promotes e-cigarette use in media campaigns (https://bbc.in/2NpLAJV), can hardly be compared with the situations in countries where advertising of e-cigarettes is banned or severely restricted, such as Finland, Greece, Malta, and Slovenia.
They say that I did not detail the views of international and national organizations that take a much more cautious approach than PHE. Some were listed in the online appendix, but they may wish to consult the long list collated by Simon Chapman, PhD (http://bit.ly/2HmDQVj).
They argue that “evidence available after the NASEM [National Academies of Sciences, Engineering, and Medicine] review closed provides further support” but cite a single study. This evaluated the role of e-cigarettes in smoking cessation in a highly selected group of individuals who had already signified a desire to quit, evaluating e-cigarettes as one element of a package that included a behavioral intervention.1 That trial did not include a comparison with varenicline, shown to be significantly more effective than nicotine replacement therapy used in the control group.2 Moreover, it gives us little information about the effectiveness of e-cigarettes when used without behavioral support, a concern given other data showing that e-cigarettes are associated with reduced quitting. I do, however, agree that there has been more evidence since the NASEM report, but much of it has reported risks associated with e-cigarettes, with two studies showing a strong link between a failure to find adverse effects and conflict of interest.3,4
They say that “rates of youths ever vaping have not increased in the United Kingdom in the last three years.” Yet data published in February 2019 show that the percentage of those aged 11 to 18 years who have tried e-cigarettes has increased from 6.5% to 11.7% between 2014 and 2018 while the corresponding figures for regular users have increased from 1.6% to 3.4% (http://bit.ly/2Z7WJpP). Crucially, JUUL was only launched in the United Kingdom in July 2018.
PHE has made considerable use of the 95%-safer figure, so it is important to examine its origins. As it is so precise, readers are entitled to assume a process of quantifying the risk as, otherwise, statements such as “much” or “substantially” safer would have been used. The only published study using a formal methodology to estimate a figure is the article by Nutt et al.5 The original PHE report provides no such quantification but instead cites two references to justify it. One is the article by Nutt et al. The second is a fact sheet submitted to a Parliamentary inquiry. This was published in several versions. The second version (http://bit.ly/2Hkzjmm) includes the 95% figure but gives, as the source, a review that makes no mention of it.6 In the fourth version, the 95% figure has gone, and the document now says “E-cigarettes are much less harmful than smoking but not 100% safe.”
Finally, they say that concerns that have been raised about whether the tobacco industry played a role have been rebutted. However, the simple statement that participants were told that an organization received no industry funding fails to address the concerns that remain about a complex set of relationships in which the tobacco industry does feature.7
CONFLICTS OF INTEREST
M. McKee is immediate past president of the European Public Health Association, which has expressed major concern about the promotion of e-cigarettes.
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