E-cigarettes - safe for now

Last month I posed the question of whether British anti-smoking groups would follow in the foot-steps of their American cousins and call for e-cigarettes to be banned. 

As I mentioned, ASH (UK) has a remit of encouraging safer forms of nicotine use (they support the legalisation of snus, for example). Furthermore, the amount of money British anti-smoking groups receive from pharmaceutical companies is a trickle compared to the river of cash spent in the US by GlaxoSmithKline, Pfizer and Johnson & Johnson (the latter, via the RWJF).

This question has now been partly answered by an ASH (UK) fact-sheet [PDF] which states the organisation's position:

ASH supports a harm reduction approach to tobacco, that is, we recognise that whilst efforts to help people stop smoking should remain a priority, many people either do not wish to stop smoking or find it very hard to do so. For this group, we believe that products should be made available that deliver nicotine in a safe way, without the harmful components found in tobacco.

Most of the diseases associated with smoking are caused by inhaling smoke which contains thousands of toxic chemicals. By contrast, nicotine is relatively safe.

Therefore, e-cigarettes, which deliver nicotine without the harmful toxins found in tobacco smoke, are likely to be a safer alternative to smoking. In addition, e-cigarettes reduce secondhand smoke exposure since they do not produce smoke.

This is level-headed stuff and is good news for smokers who wish to quit. There is an abundance of evidence (albeit anecdotal) that the e-cigarette is the most effective smoking-cessation device yet invented. Banning it would be madness from a public health point of view. 

ASH (UK)'s assertion that e-cigarettes do not create secondhand smoke is a statement of the obvious, but is nonetheless welcome since their American namesakes have been making laughably hysterical claims to the contrary, such as this, from the ASH (US) website:

A new device for addicted smokers who want to be able to get their nicotine fix by “smoking” in places where smoking is prohibited, and do so by exhaling a cloud of “smoke” made up of a chemical which is both toxic and addictive.

This new product, already being sold and used in many U.S. cities, is called an e-cigarette...

If you don’t want people sitting next to you – in a waiting room, restaurant, bar, or any other area where smoking is now prohibited – using one of these devices to get around smoking bans, and forcing you and your loved ones to inhale deadly nicotine – please help now!

We should be thankful that ASH (UK) haven't sunk to this level of fear-mongering. Nonetheless, they have three reservations about e-cigarettes.

1. Most deliver a low dose of nicotine which may not give a typical smoker a sufficient ‘hit’ to satisfy cravings, discouraging smokers from continuing to use them.

2. Because the products are unregulated there are some concerns about their safety since few manufacturers disclose the ingredients of their products.

3. So far, there have been no clinical trials to prove that they can help people to stop smoking. In the absence of such evidence, ASH therefore recommends that people who want to quit smoking should use nicotine replacement therapy or other proven pharmacological aids such as Champix (varenicline) or Zyban (bupropion).

I don't believe that the first point is valid. E-cigarettes offer high, medium, low and zero nicotine cartridges and I haven't heard users complain that the high nicotine cartridges are insufficient. Besides, users can take as many drags as they need to increase the dose. ASH's criticism could more accurately be aimed at pharmaceutical nicotine devices like patches and gum.

The second point is moot. Already, we are getting a clear indication that there are very few ingredients in the devices and that none of them - nicotine included - are harmful at the doses found. Nevertheless, regulation is required and is welcomed by the e-cigarette industry. As ASH points out: 

...e-cigarettes are subject to general consumer protection laws and it is the responsibility of trading standards officers to rule on their safety.

That should be sufficient regulation.

The third point is also questionable. It is true that clinical trials have not yet shown e-cigarettes to be effective as smoking-cessation devices, but then they are not being marketed as such. On the other hand, they have not been shown to be harmful. The same cannot be said for Champix and Zyban which, between them, have been linked to 317 suicides or attempted suicides. 

In July, the FDA ruled that black-box warnings must be put on both these products:

FDA: Boxed Warning on Serious Mental Health Events to be Required for Chantix and Zyban 

The U.S. Food and Drug Administration today announced that it is requiring manufacturers to put a Boxed Warning on the prescribing information for the smoking cessation drugs Chantix (varenicline) and Zyban (bupropion). The warning will highlight the risk of serious mental health events including changes in behavior, depressed mood, hostility, and suicidal thoughts when taking these drugs.

This leaves consumers with a choice between a product that has not been clinically proven as a stop-smoking device but is safe, and two products that have been proven to cause psychotic disorders. That ASH (UK) is recommending the latter may seem perverse, but at least they are still allowing a choice.