Doctors are both sceptical of and poorly informed about e-cigarettes and nicotine, failing to realise how dramatically harm reduction approaches can change the lives of their patients, Dr Colin Mendelsohn, a leading expert on smoking and vaping in Australia, told the annual E-Cigarette Summit held in London and Washington DC this week.
He said that withholding a legitimate treatment option that could prevent a life-threatening illness was a breach of obligation to patients, writes Chris Bateman for MedicalBrief.
Disconcertingly low quit and abstinence rates among nicotine addicts rose impressively once vaping alternatives to combustible tobacco were prescribed, he said, illustrating this with several examples of patients he and other GP’s have successfully treated with vaping options.
Mendelsohn said a lack of training in, and knowledge of, harm reduction approaches among doctors, plus common misconceptions about the harm that nicotine can do, when added to Cochrane Review data of low long-term abstinence rates of 6% to 15% at six to 12 months, combined to discourage doctors and patients. In the real-world setting, abstinence rates were even lower than those in the Cochrane review, he emphasised.
“That’s why all the options should be on the table to help us help our patients. Harm reduction approaches are commonly used in medical practice; think of methadone and controlled drinking as examples.” He added that vaping nicotine “ticks all the boxes”.
The summit
“The E-Cigarette Summit – Science, regulation and public health” was held from 7-8 December 2021 and describes itself as a neutral meeting point for scientists, regulators, industry, public health and practitioners “to explore the latest research on e-cigarettes and facilitate respectful debate on what remain highly controversial issues”.
Owned by Smooth Event Management in the United Kingdom, the summit is funded through delegate ticket sales, does not accept sponsorship or funding from commercial or government organisations, and has no commercial links or involvement with the tobacco, pharmaceutical or e-cigarette industries.
Doctors sceptical
Doctors were sceptical about the effectiveness of vaping and concerned about safety and addictiveness of alternative nicotine devices, Mendelsohn told the summit. In most countries, doctors acquired knowledge of vaping from the media, which was often misleading, alarming and negative.
Doctors were naturally conservative and risk averse, and were failing to ask patients about vaping.
“They also share common misconceptions. A United States survey showed that four out of five doctors ‘strongly agree’ with the idea that nicotine directly contributed to cardiovascular disease (83.2%), COPD (80.9% and cancer (80.5%), whereas in fact nicotine use [i]per se[/i] represents minimal risk for serious harm to physical health,” he said.
“Vaping is the most popular quitting aid, more effective than nicotine replacement therapy, and probably better than other mono therapies and medications. Long term use is far less harmful than smoking. When smokers switch, they have improved health, reduced exposure to toxins, save money and feel and smell a lot better,” he averred.
If other methods were unsuccessful, withholding legitimate treatment which could be lifesaving for many smokers, breached a duty of care and was unethical.
Patient responses positive
Using vaping satisfied the four principles of bio-ethics: autonomy, beneficence, non-maleficence and justice.
Mendelsohn, who founded the Australian Harm Reduction Association, said he was forcibly struck by how, when his colleagues learned about vaping and engaged with it, they became very strong supporters.
He cited a Melbourne GP, ‘Dr Carolyn’, who before 2020 had never heard of nicotine e-juice, saying she wrote to his association to describe vaping as ‘life-changing’ for her patients, with huge financial savings.
Her patients had told her that they finally had their lives back, could run around with their kids again, their smell and taste had returned, other health conditions had improved, while mental health and concentration improved. But by far the most common phrase his colleague heard was, “vaping has saved my life!”.
Mendelsohn said smoking hurt disadvantaged groups the hardest as they had higher smoking prevalence and high relapse rates. Smoking remained a major cause of health and financial inequity.
“People smoke to cope with stress and difficult life circumstances, and it’s normalised in these populations where the income gap is increasing,” he said.
Another colleague, ‘Dr Gillian’, a Sydney GP, researched vaping and began prescribing it. After one year she reported being “blown away” by positive feedback from patients.
“They said things to her like, “after three months I feel I can breathe again. The terrible burden of shame and guilt lifts and the financial benefits are huge for some. It’s a huge relief just to help one person be free from the shackles of cigarettes, but I know there are thousands of Australians who need this help right now,” she had added.
Mendelsohn said GPs that he knew were “genuinely amazed” once they began prescribing vaping, and had become passionate advocates.
One of Mendelsohn’s patients, who he helped to quit through vaping, illustrated a much-encountered heavy smoker’s profile. The 40-year-old male lived alone on a disability pension, had a schizoaffective disorder, with alcohol abuse, and had been smoking since the age of 15. He earned A$400 per week, his cigarettes cost him A$280 per week and rental A$115 per week – and had an “unsurprisingly large” credit card debt.
“He told me ‘smokes’ had been his best friend since he was 15 and that he always turned to them when times were bad.”
All treatment options failed – Mendelsohn said he put the patient on Bupropion, two nicotine patches and 4mg nicotine lozenges, but he always relapsed when stressed.
Unwilling to trial Champix for his mental illness, the man gained between five and 10 kilograms whenever he tried to quit.
“So, I thought we’d try vaping. I put him on a small, good ‘all-in-one’ unit in July 2016. He stopped smoking immediately and after a week stopped the lozenges.
“Over the next four years he tapered down, and by December 2020 he’d ceased vaping altogether, paid off his credit card, was healthier with more energy, more motivated, joined a gym, had less anxiety and was coping better with stress. His sleep apnea was 50% better and he was much more alert. He was eating better, but with no weight gain.”
The patient’s feed-back?
“He told me, ‘I never thought I’d be able to quit. It’s the best thing I’ve ever done. The e-cigarettes helped me manage the bad days’.”
Mendelsohn concluded: “Vaping may have a special role in such populations that are currently being left behind as we hasten slowly toward the endgame.”
The E-Cigarette Summit – Science, regulation and public health
See also from the MedicalBrief archives
In world first, NHS may prescribe e-cigarettes for smoking cessation
Draft UK guidelines to tackle the health burden of smoking
Tobacco harm reduction – Patients before prejudices
WHO versus Public Health England over e-cigarettes
Prominence of e-cigarettes is a symptom of failure to address smoking