Q. How does Public Heath England’s report on e-cigarettes differ from that of the US National Academies of Science, Engineering, and Medicine?
The differences between the two reports have been summarised in a paper by Amy Fairchild and colleagues.1 This sets out in detail the fundamental differences in approach to the issue, as well as listing the differences in the specific conclusions. In brief, Public Health England (PHE) has focused on protecting existing smokers and has consistently downplayed the risks that e-cigarettes might recruit non-smokers, particularly children, to nicotine addiction and, subsequently, smoking.2 In contrast, the US National Academies of Science, Engineering, and Medicine (NASEM) report, consistent with the wider international consensus, has taken a population-based approach; looking at the overall impact on tobacco-related disease.3
Q. What are the opinions of these two bodies on randomised controlled study evidence to date?
The NASEM report has placed a high priority on evidence from randomised controlled trials, which are recognised internationally as the gold standard.3 PHE argues that such trials do not capture the effects of e-cigarette use outside the specific conditions of a trial.2 However, subsequently, those involved in the PHE report have promoted the findings of one of the very few trials that has been conducted, which found that e-cigarettes, when administered in a highly controlled setting, in which subjects were also receiving an intensive behavioural intervention, achieved a higher quitting rate than was seen with nicotine patches.2 That trial itself had many limitations, including not comparing e-cigarettes with the most effective pharmaceutical interventions and, obviously, saying nothing about the use of e-cigarettes when used outside a structured behavioural programme. Thus, the does seem to be a degree of inconsistency here.
Q. Where do other countries stand on e-cigarettes and why is England so much at odds with the rest of the world?
Many people have sought to understand why it is that England take such a different view from almost everywhere else in the world. In a paper I published recently in the American Journal of Public Health,4 I concluded that this was because a small community of researchers and advocates in England had come out very strongly in support of e-cigarettes at a time when others were quite sceptical. They promoted heavily the claim that these products were 95% safer than conventional cigarettes despite a lack of empirical evidence to support it. This claim has now been disseminated widely, even though there is now much evidence accumulating to challenge it. However, when one is identified so strongly with a statement, over a long period of time, it is very difficult to go back on it.5
Q. How has Juul contributed to the use and health impact of e-cigarettes?
Juul e-cigarettes have only been available in the United Kingdom for a relatively short time. However, almost by design, in terms of their unobtrusiveness and flavours, they have proven extremely attractive to young people. This has led to concerns about a new generation growing up nicotine dependent.
Q. What further studies are needed to ensure consistencies of recommendations worldwide?
First, we urgently need clinical trials to determine once and for all whether these products actually are effective as a cessation devices, comparing them with the best alternatives, in particular varenicline or combination nicotine replacement therapy (NRT) (patches + short-acting NRT). Second, it is essential that all flavours being used are tested for safety when vaporised and inhaled. Currently, they have (mostly) been shown to be safe as food additives when eaten, but this is entirely different. Third, we need further follow-up studies to track the transitions between smoking, e-cigarette use, and abstinence (and combinations thereof) over time. Fourth, drawing on the very successful research on tactics used by tobacco companies (most of which also produce e-cigarettes) we need detailed research, drawing on cognitive psychology, corporate research etc. to understand how they are operating.