Did Public Health England get it right over e-cigarettes?

Public Health England’s endorsement of e-cigarettes might be premature.

Public Health England’s endorsement of e-cigarettes might be premature. In the image, three different types of e-cigarettes

Best estimates show electronic cigarettes are 95% less harmful to your health than normal cigarettes — that was the bold statement issued by Public Health England (PHE) in its recent report on the safety and effectiveness of e-cigarettes as smoking cessation aids. But was there strong enough evidence to warrant this endorsement?

The 95% figure came primarily from a 2014 paper by David Nutt, British psychiatrist and neuropsychopharmacologist specialising in the research of drugs, and colleagues published in European Addiction Research, again cited in a briefing report to the all-party parliamentary group on pharmacy in the same year. Nutt’s paper described the outcomes of a two-day workshop in which a panel of experts, convened by the Independent Scientific Committee on Drugs (now called DrugScience), which Nutt founded, considered the relative importance of the harms related to the use of nicotine-containing products. The group ranked cigarettes as the most harmful nicotine delivery system, with an overall harm score of 99.6, and e-cigarettes as having only 4% of the maximum relative harm. And so it came to pass: e-cigarettes are 95% less harmful than standard cigarettes.

But Nutt and his co-authors in the original paper point out several limitations to their results, not least that there was a “lack of hard evidence for the harms of most products on most of the criteria” the panel had used to score the different nicotine delivery systems. They also conceded that the experts had not been selected based on any pre-specified criteria in terms of expertise in tobacco control. Hardly the most solid foundation on which to base public health policy.

And since the report was published on 18 August 2015, a US public health body has issued its own, somewhat different, judgement on e-cigarettes: of 24 companies whose products were tested, 21 had at least one product that, when tested under normal-use conditions, produced high levels of one or both of the cancer-causing chemicals formaldehyde and acetaldehyde. The Center for Environmental Health is now suing e-cigarette makers in California for failing to warn consumers about the effects of the chemicals, as required under California’s strong consumer protection laws.

The Royal Pharmaceutical Society (RPS) was quick to express concern over PHE’s support for e-cigarettes. “No one can be sure of the consequences of long-term use on health and further research is needed to determine this,” said Howard Duff, RPS director for England, when PHE published its report. And experts are now beginning to unpick the recommendations made by the public health body. Writing in The BMJ on 15 September 2015, Martin McKee at the London School of Hygiene and Tropical Medicine and Simon Capewell at the University of Liverpool argue that the available evidence about e-cigarettes “suggests that the debate is far from over and questions remain about their benefits and harms”.

Questions do remain about the safety of e-cigarettes and pharmacists need high quality evidence-based information on which to base the advice they give to their customers.

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Citation
The Pharmaceutical Journal, PJ, 19 September 2015, Vol 295, No 7880;295(7880):DOI:10.1211/PJ.2015.20069361