Royal College of Physicians recommends e-cigarettes for smokers

A few months ago I wrote here about the rise of e-cigarettes. In that post I pointed out that e-cigarettes are far less harmful than tobacco, and should be marketed as a safer alternative to smoking. There has been an interesting update on this topic today, with the Royal College of Physicians (RCP) recommending that all smokers be offered and encouraged to use e-cigarettes.You can read my previous post for some of background, but put simply, e-cigarettes vaporise nicotine to allow it to be inhaled (hence it being known as “vaping”). This differs from smoking, where tobacco is burned and the smoke inhaled. This accounts for the primary difference between vaping and smoking; tobacco burning creates thousands of chemicals, 10% of which are known to cause cancer. People inhale far fewer chemicals when vaping, making it 95% safer than smoking.The RCP released a report today (April 28^th) stating that

"e-cigarettes are likely to be beneficial to UK public health. Smokers can therefore be reassured and encouraged to use them, and the public can be reassured that e-cigarettes are much safer than smoking"

They go on to state that current evidence shows:

• E-cigarettes are not a gateway to smoking.
• E-cigarettes do not result in the normalisation of smoking.
• E-cigarette use is likely to lead to quit attempts that would not otherwise have happened.
• The dangers of long-term e-cigarette are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure.

An excellent Cancer Research UK blog post on this topic points out that this reduced harm of vaping is something we should focus on. They emphasise that a significant number of people may be unable, or simply not want, to give up smoking. For these people, the aim should be to reduce the danger of their habit by encouraging them to use e-cigarettes rather than traditional cigarettes. This harm reduction strategy has worked well in other cases, such as needle exchanges for intravenous drug users.This is what the NHS already recommends, in the form of nicotine replacement therapy. It has been shown, however, that the delivery of nicotine to the brain via vaping is far more similar to smoking than in nicotine replacement therapy. As a result smokers seem to prefer vaping, and e-cigarettes have now replaced nicotine patches and gum as the most popular aid in quitting smoking in the UK.It has been shown that an overwhelming majority of e-cigarette users are ex-smokers, or current smokers who are trying to cut down or quit. Considering the human toll of smoking (270 deaths in the UK every day), it is commendable that the RCP have recommended e-cigarettes to smokers. While there are still problems with vaping (particularly in marketing to children), the advantages for current smokers are undeniable. The use of alternative sources of nicotine is safer, and should be part of any strategy to reduce the harm of tobacco.

Smoking vs Vaping

Vaping has become remarkably popular in the UK over the last few years. Estimates now suggest that over 2.5 million people in the UK use e-cigarettes and that number is rising. However, as a recent conversation with my wonderful sister-in-law showed me, people are divided over whether this is a good thing or not.Smoking is one of the most damaging habits we can choose to take up, being the single biggest cause of preventable death in the UK (as I described in a previous blog). We have known for years that people “smoke for the nicotine, but die from the smoke”; standard cigarettes burn tobacco, generating over 7,000 different chemicals, at least 72 of which are known to cause cancer.In contrast, e-cigarettes vaporise nicotine to allow it to be inhaled. This difference is perhaps the biggest argument for vaping that can be made, as most current evidence suggests that it is far safer. Public Health England (a UK governmental body) estimates that e-cigarettes are “around 95% less harmful that tobacco”, leading 53 experts to recently write a letter to the WHO, urging them not to classify e-cigarettes the same as regular cigarettes. Furthermore, the Royal College of Physicians has also called for e-cigarettes to be marketed as a less harmful alternative to smoking.However, it is important that e-cigarettes are seen as the lesser of two evils, rather than as something “good” or “safe”, a fact that seems to be ignored by advertisers, who benefit from a lack of marketing regulation that applies to other addictive substances like cigarettes, alcohol or gambling.There is pretty good evidence now that several cancer causing agents can be found in e-cigarettes. Some of the flavourings added to e-cigarettes have been found to contain high levels of chemicals known to cause lung cancer. Furthermore, the well-known carcinogen formaldehyde has been identified at levels 5 times higher than in normal cigarettes. This study has not been replicated however, but it is worth keeping an eye on.Additionally, nicotine itself is a poisonous substance, particularly in pregnancy, as it can both cross the placenta and is present in breast milk. While the dose of nicotine supplied by an e-cigarette is lower than that supplied by a regular cigarette, it is overwhelmingly clear that people should neither smoke or vape during pregnancy.Finally, it is important to discuss the potential of vaping as a gateway drug to smoking. Do people who would otherwise not smoke take up vaping? There isn’t a huge amount of data to answer that question right now, and the data we have is mixed.Some studies suggest that this may not be the case, and the increased e-cigarette use is resulting in a decreased in the number of new smokers. However, other studies have shown the opposite, that many teens that use e-cigarettes do so for the novelty and flavour. The two biggest studies show that only a subset of those considered “gateway smokers” will move on to be regular smokers however, meaning that it is likely that further follow-up studies “will be unable to demonstrate a major gateway to heavy tobacco use”.E-cigarettes have only been on the market for a few years, so it is impossible to tell what the long-term effects of their use will be. While there still isn’t sufficient evidence to be sure, indicators suggest that vaping is a lot less dangerous than smoking, so it probably makes sense to market e-cigarettes as a safer alternative for nicotine addicts.However, making e-cigarettes attractive to teenagers and children should obviously be banned. It is extremely worrying that many flavours currently available are targeted at kids (including “cotton candy” and various fruit flavours). After all, nicotine is an extremely addictive substance, so the normalisation of vaping in this group should be prevented.This current lack of regulation needs to be corrected, but it must be acknowledged in any regulation that e-cigarettes are less harmful than regular cigarettes, and that excessive regulation may drive people to smoking in order to get their nicotine fix. Given the horrendous toll of tobacco smoke, this is something we cannot allow.

Smoking is even more dangerous than we realised

The UK government has finally decided to push ahead with legislation on plain packaging for cigarettes before the general election in May. This comes after years of inexcusable delay and extensive lobbying by the tobacco industry. In a brazen attempt to bully the government, the tobacco companies have even threatened to sue for damages if such legislation is introduced. Plain packaging is already required in Australia (and is now being introduced in Ireland) and has been shown to be an effective anti-smoking measure (evidence of which can be found here, here, here and here).We are all fully aware that smoking is one of the most dangerous activities that you can do, but recent work has emphasised just how dangerous. Two studies (one in the New England Journal of Medicine, the other in BMC Medicine) have shown that smoking is associated with more diseases than previously thought, and plays a role in far more deaths. The first study was carried out in Australia, and followed over 200,000 people for 4 years to assess the effect of smoking on their lifespan. This was a well carried out, prospective study (see below for explanation). They found that death rates in smokers were 3-times higher than in non-smokers, and that smokers die an average of 10 years before their non-smoking counterparts. Furthermore, up to 67% of deaths in smokers can be attributed to their habit. To put it simply, for every three people you see smoking outside a pub, two of them will eventually die from a smoking related illness if they don’t quit. It’s a shocking toll.The second study was a meta-analysis (see below for explanation) of 5 previous US studies, including nearly a million people. They showed that at least 30 diseases are associated with smoking, including cancers of almost every site (pancreas, bladder, breast, kidney...). It’s a terrifying list, which I have included below, but there is some good news. The BMC Medicine study confirmed that if somebody stops smoking, not only will the damage stop accumulating, but the body can begin to heal itself. The earlier the smoker quits the better, and those who quit early have the same lifespan as non-smokers.These studies emphasise the need for continued efforts to reduce the levels of smoking. Measures such as the plain packaging of cigarettes, and the banning of smoking in cars are positive steps. The UK government's vote on the issue before will take place before May, so hopefully there will be progress soon. Fingers crossed.https://twitter.com/CRUK_Policy/status/573898151842701312Diseases associated with smokingLaryngeal cancer - 103.8 times more likely to die from than non-smokersLung cancer - 22.9Lip and oral cavity cancer - 5.6 Oesophageal cancer - 5.1Urinary bladder cancer - 3.9Pancreatic cancer - 1.9Liver cancer - 1.8Stomach cancer - 1.7Colorectal cancer - 1.6Breast cancer - 1.3Kidney and renal pelvis cancer - 1.2Acute myeloid leukaemia - 1.1Rare cancers - 1.1Cancers of unknown site - 2.7Chronic obstructive pulmonary disease (COPD) - 25.0Aortic aneurysm - 10.1Ischemic disorders of the intestine - 6.1Other arterial disease - 5.6Ischemic heart disease - 3.0Liver cirrhosis - 2.6Infection - 2.5Hypertensive renal disease - 2.4Unknown causes - 2.2Stroke - 2.1Atherosclerosis - 2.1Other digestive diseases - 2.1Additional rare causes - 2.0Other heart disease - 1.9Pneumonia, influenza, and TB - 1.9Hypertensive heart disease - 1.9Other respiratory diseases - 1.9Renal failure - 1.9 Diabetes - 1.5Further ExplanationProspective study: This is the gold standard of medical studies. In a prospective study, people are recruited to look specifically at a certain thing (in this case, the effect of smoking on lifespan). The study is planned ahead of time, and controls are put into place to ensure the highest quality data. This differs from a retrospective study, where data that has already been gathered is analysed to draw conclusions about a certain outcome. This type of study can be prone to significant bias, because unlike a prospective study, you cannot control the population you are studying. It is also more difficult to separate correlation from causation using a retrospective study. It is far easier and cheaper than a prospective study however, and very often the only option.Meta-analysis: This type of study involves the combining of several studies in the hope of revealing patterns in the results of those studies. A meta-analysis allows the study of far larger numbers of people, but can be severely affected if one or more of the individual studies is poorly carried out.