As the UK prepares for a Smoke-free 2030 goal, the use of vaping as a means of doing so has again created divisions, with the US banning the popular Juul e-cigarette, notes Medical Brief.
A new report, commissioned by the UK’s Secretary of State for Health and Social Care, provides recommendations to achieve a “Smoke-free 2030”, reflecting the government’s ambition to reduce the smoking rate from 13.5% to 5% by the end of this decade.
Authored by Dr Javed Khan OBE, and released on 9 June 2022, “The Khan Review: Making Smoking Obsolete”, assesses the impact of current public health policies, finding that, “without further action, England will miss the smoke-free 2030 target by at least seven years, and the poorest areas in society will not meet it until 2044”.
“To hit the smoke-free 2030 target,” it concludes, “we must accelerate the rate of decline of people who smoke, by 40%.”
The report offers evidence-based recommendations – four of them “critical” – to accelerate progress and save more lives more quickly. They serve both as guideposts for the UK and as a model for what the US could likewise do to end America’s smoking epidemic.
In both nations, report Clifford Douglas and Caitlin Notley in MedPage Today, smoking remains the leading preventable cause of death.
The report’s “must-dos” include:
1. Increase investment. Comprehensive financial investment is needed for smoking cessation treatment. If the government cannot/will not provide such funding, it should “make the polluter pay”, imposing additional levies on cigarette companies.
2. Increase the age of sale. The government should increase the age of sale from 18, by one year, annually until no one can lawfully buy cigarettes. (The minimum age in the US is 21, with no annual increase.)
3. Promote vaping as a harm reduction approach. Increase promotion of e-cigarettes to help people quit smoking tobacco. “We know vapes are not a ‘silver bullet’ or totally risk-free, but the alternative (of combustible tobacco use, or smoking) is worse.”
4. Improve prevention in the National Health Service (NHS). Prevention must become a central focus of the NHS’ tobacco control efforts. It must offer smokers advice and support to quit in “every interaction with health services”, including with GPs, hospitals, midwives, pharmacists, etc.
The report also proposes requiring tobacco licences for retailers, changing the appearance of cigarettes and their packaging, expanding smoke-free public places, mass media campaigns, raising cigarette taxes, and ending duty-free privileges for tobacco products.
Finally, Khan urges the government to accelerate plans for healthcare practitioners to prescribe e-cigarettes (in addition to their continued sale as non-medicinal consumer products). This will help make harm reduction approaches acceptable to those who require medical reassurance, and accessible to others who can’t afford e-cigarettes at retail prices.
These recommendations echo New Zealand’s Smoke-free Aotearoa 2025 plan, which seeks to end smoking and promotes e-cigarettes as having “the potential to make a contribution to the Smoke-free 2025 goal”.
In stark contrast to the consensus of government and public health organisations in those nations, the US is mired in a polarised debate pitting concern regarding the risks of e-cigarettes for youth against their potential to help addicted adult smokers quit. The emphasis on protecting youth has, to its credit, succeeded in reducing youth e-cigarette use by more than 60%, down to 7.6%, in the past two years, while simultaneously, the youth cigarette smoking rate has plummeted to a low of only 1.5% (mitigating the concern that youth vaping might encourage smoking).
Youth vaping is no longer an “epidemic”. But these efforts, which too often inaccurately portray the risks of e-cigarettes, have led to public misunderstanding regarding the substantially lower health risks of e-cigarettes compared with combustible tobacco products.
And this has impeded the promotion of tobacco harm reduction to the more than 30m adults still smoking.
Recently, the FDA announced it would ban Juul e-cigarettes due to “unresolved questions … potential toxicity”, although it said it is unaware of any immediate hazard associated with the product.
TIME reports that the CEO of the American Lung Association called the decision “long overdue and welcome” while anti-smoking group Truth Initiative called it a “huge public health victory”.
Yet, while more than 2m adults have switched from cigarettes to Juul, potentially avoiding more than 1m deaths from smoking in the coming years, Juul is no longer favoured by young people, with only 0.6% of youth reporting having used a Juul product in the past 30 days.
Some experts noted the irony that an e-cigarette popular with adult smokers trying to quit may be banned while billions of aggressively marketed, more hazardous, combustible cigarettes continue to be sold with impunity.
It took less than 48 hours for a court to issue an emergency stay, allowing Juul to keep selling its e-cigarettes while its lawyers prepare a full appeal. Juul’s lawyers called the FDA’s ruling – which the agency said was based on inadequacies in Juul’s toxicology data – “arbitrary and capricious”, arguing that Juul can benefit public health by helping adult smokers switch to a less dangerous product.
“Juul is the most thoroughly researched #ecig in history,” Jonathan Foulds, a professor of public health sciences at Pennsylvania State University, tweeted after the FDA’s decision. “Banning this lifesaving escape route from smoking because some ‘potentially harmful chemicals’ may leach from some pods is like locking the door to the fire escape because the steps may be slippery.”
Like any tobacco product, e-cigarettes are not full-stop safe. Experts agree no one who is not currently smoking should start vaping.
But for those who already smoke, studies suggest e-cigarettes are a less-dangerous way to consume nicotine, potentially providing a bridge between lethal cigarettes and quitting nicotine entirely.
Not long ago, the country’s top tobacco regulators were cautiously optimistic about that potential. In 2017, Dr Scott Gottlieb then FDA commissioner, and Mitch Zeller, then director of the FDA’s Centre for Tobacco Products, described a framework for reducing tobacco-related death and disease, including promoting e-cigarettes for adults wanting to stop smoking, along with nicotine gums and patches.
Then vaping took off among teenagers, with Juul, especially, spreading like wildfire. As the teen vaping problem snowballed and lawmakers, parent groups, and public-health organisations started speaking out against Juul, the FDA had little choice but to act aggressively.
To be clear, Juul has made mistakes. Its first marketing campaign – which the company repeatedly denies was meant to attract kids – was, at the very least, ill-advised. It was too easy, for too long, for underage customers to buy Juul products online and in stores.
It then accepted $13bn from tobacco giant Altria, raising significant conflict of interest concerns.
The FDA’s denial didn’t focus on those public mistakes. Instead, it ordered Juul off the market because “insufficient and conflicting data” raised concerns about genetic damage and chemicals leaching out of Juul’s e-liquid pods. The FDA said it does not have “information to suggest an immediate hazard” linked to Juul products, but any concern about health risks must be taken seriously.
Yet Juuling doesn’t only happen in schools. Adult smokers also use Juul to ditch cigarettes– and for them, the FDA’s decision was not a victory.
A research review last year concluded that e-cigarettes could help about three additional smokers out of 100 ditch cigarettes, compared with traditional nicotine-replacement therapies like gums and patches. That’s not a massive difference – but it is still a difference, both for public health and for those three hypothetical smokers.
The FDA continues to promote policies to reduce the appeal of conventional cigarettes, like reducing nicotine to non-addictive levels and eliminating menthol as a flavour.
It has also, recently, authorised for sale 23 e-cigarette brands based on the agency’s assessment that they are “appropriate for the protection of public health”. Adhering more consistently to this approach based on the “continuum of risk” across different tobacco and nicotine products would align with the approaches being pursued in the UK and New Zealand.
The over-riding objective should be to protect the public from harm, especially grievous harm. The greatest harm to health is overwhelmingly caused by inhaling combustible tobacco smoke, which is responsible for virtually all “tobacco-related” deaths.
Nicotine causes dependency, but does not itself cause the many diseases resulting from inhaling burned tobacco, a fact misunderstood by most physicians. It is their duty to help smokers quit whenever possible, supported by cessation medications and counselling. And for those who cannot or will not use cessation medications, they should be encouraged to switch to less harmful nicotine sources, like e-cigarettes.
Daily, more than 1,300 Americans die from smoking. At the same time, there have been no credibly reported deaths from exposure to the aerosol of nicotine-based e-cigarettes.
If Juul doesn’t win its appeal, many adult users will probably switch to another e-cigarette, either one that has been authorised by the FDA or remains for sale as it waits in regulatory limbo
Zeller, for his part, wishes the tobacco-control community was more willing to look for common ground regarding vaping, adds TIME.
“I wish that the pro-e-cigarette people were not completely dismissive of the concerns of the other side about unintended consequences like youth use and addiction,” he says. “I also wish the anti-e-cigarette people were more open-minded on the upside of a properly regulated marketplace.”
Clifford Douglas, JD, is the director of the University of Michigan Tobacco Research Network and an adjunct professor at the University of Michigan's School of Public Health. Caitlin Notley, PhD, is professor of addiction sciences and lead of the Addiction Research Group at the Norwich Medical School, University of East Anglia.
khan-review-making-smoking-obsolete
MedPageToday article – A Bold U.K. Plan to End the Smoking Epidemic (Open access)
TIME article – It's Too Simple to Call the Juul Ban a Public Health Triumph (Open access)
See more from MedicalBrief archives:
E-cigarette Summit: Vaping improves odds of quitting tobacco smoking
E-cigarette Summit – Unlocking the harm reduction potential of e-cigarettes
Anti-vaping bias undermines e-cigarette research? Study raises questions