First do no harm – smoking and the ethics of vaping…

 

Michael McBride is crystal clear; our Chief Medical Officer believes too many people are vaping and this is a bad thing.  In a recent TV interview he was unambiguous in his discouragement of e-cigarettes.    The views of CMO are important, people listen and people take note.  He’s not alone; the British Medical Association, WHO, European Commission and the Welsh Assembly are all censorious.   So are they right?

One thing on which Michael McBride and I agree is the need to reduce tobacco harm.   Much effort is applied to this public health problem but we still have too many smokers; about 22% smoke and it’s a key reason for social inequalities in health. In some poorer regions of Belfast 54% of the population smoke whereas in North Down the figure is 10%.   Catholics are three time more  likely to smoke compared to Protestants which suggests a sectarian issue but this I feel is down to culture; priests traditionally were smokers while smoking did not fit well with the Protestant work ethic.  Catholics smokers are well aware of a particular prickly dilemma; if it is improper to smoke while praying, when smoking is it inappropriate so say a quick prayer?

The three Abrahamic faiths seem pretty relaxed with smoking.  I suppose widespread tobacco use has come to us relatively recently compared to the rule books of these monotheist religions and since cigarettes don’t make you beastly with lust or  covetous of money it was largely ignored by the good books that is until we got ISIS who dole out lashes for having a sneaky drag.  Unlikely this latter development will have much of an impact on smoking rates here so it’s health professionals who remain the vanguard in the war on tobacco.

Twenty years ago, those who had tobacco-control as their day job, first realised, then argued, that public health needed to support the innovation of new forms of nicotine.   Karl Fagstrom, a leading scientist in smoking control said in 2003 that;

the battle against tobacco related mortality is over when NRT is not used for cessation anymore but instead of cigarettes”.

This vision should have set the agenda for the next 10 years of smoking control but sadly it didn’t.   The pharmaceutical industry, who produce licensed Nicotine Replacement Therapy (NRT); patches, gum etc, was aggressively resistant to any discussion on developing improved and safer nicotine delivery systems; safer than a cigarette yet satisfying to the smoker.  Why this should be I never fully understood.  I remember at meetings having heated discussions with senior people at GlaxoSmithKline and Pharmacia (now Pfizer) who, it seemed to me at least, were more interested in corporate image than public health or profit for that matter.  Developing better nicotine delivery systems might make Big Pharma more like Big Tobacco and that just wouldn’t do.

And there was the complex issue of regulation.  NRT for stopping smoking was, and is, the most rigorously regulated form of nicotine; the most deadly – cigarettes – is hardly regulated at all.   To successfully market an innovative NRT product seemed impossible in the early years of this century.  Then the medicines regulator – MHRA – had a “Road-To-Damascus” moment and caved into the pleadings and concerns of people who had written widely on the lack of a level playing field in nicotine regulation.

A report from 2005  secured significant relaxation for the use of licensed NRT particularly in pregnancy and heart disease – where it was almost banned – and reduced the public health obsession with “cessation” – stopping for good is great but what about those who cannot stop?   So we got “temporary abstinence” and “stepping down to stop” and finally “harm reduction”.       But licensed NRT products are not very attractive for harm reduction.  E-cigarettes are.

E- cigarettes have become a popular crutch for many who have or are attempting to quit smoking or simply wish to avoid cigarette smoking’s long-term complications. The battery-operated nicotine delivery device simulates the act of tobacco smoking through physical sensation, appearance and even flavour.   Invented by Beijing pharmacist, Hon Lik, it has now secured global commercial success and I predict that Hon Lik will become famous for his contribution to public health.   Of the myriad e-cigarettes brands on the market none is licensed.  This is unhelpful. It might be the lack of licensing that gives the public health specialists, including Michael McBride, such a jaundiced view of the product.

It would be best for all if e-cigarettes were regulated and this might happen in 2016.  Regulation needs to assure that these devices deliver nicotine in a reliable and consistent way and that they contain pharmaceutical grade nicotine (some versions have high levels of nitrosomines a chemical linked to cancer).  But this is nit-picking when it comes to saving the lives that would be otherwise lost to burning tobacco.  And off course the potential reduction in chronic diseases; heart, stroke, lung and many cancers.

The smoking public has voted and huge numbers have switched from a highly dangerous habit – smoking burning tobacco – to a much less dangerous one – vaping.  If government policy continues to vilify e-cigarettes I  would suggest its does so on something more scientific than the “precautionary principle” and a paranoid suspicion that Big Tobacco, who own the e-cigarette companies, have an ulterior motive.  To do this would be to do more harm than good.

Terry Maguire is a pharmacist in West Belfast

 

This is a guest slot to give a platform for new writers either as a one off, or a prelude to becoming part of the regular Slugger team.