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Harm reduction vs. abstinence: U.K. and U.S. take very different approaches to e-cigarettes

“In England … the pressing need to reduce the risks for current smokers frames the debate, [while] the overwhelming focus in the United States is abstinence,” the authors of a new commentary write.

In 2015, Public Health England published a report that claimed e-cigarettes are 95 percent less harmful than traditional, combustible cigarettes.
REUTERS/Toby Melville

United States and England have staked out widely diverging positions on whether electronic cigarettes help or hinder the goal of reducing tobacco smoking — positions that reflect longstanding differences between the countries in their approaches to treating drug addiction in general, according to a provocative “Perspectives”commentary published Thursday in the New England Journal of Medicine (NEJM).

“In England, where leading medical organizations regard nicotine alone as relatively benign, the pressing need to reduce the risks for current smokers frames the debate, [while] the overwhelming focus in the United States is abstinence,” write the commentary’s authors, which include Amy Fairchild, a historian of public health policy at Columbia University in New York City.

Minimizing harm

Public health officials in England and throughout the rest of the United Kingdom have, in general, taken a “harm-reduction” approach toward e-cigarettes, Fairchild and her colleagues point out.

In 2015, Public Health England (PHE), part of that country’s health department, published a report — written by a prominent tobacco-addiction researcher — that claimed e-cigarettes are 95 percent less harmful than traditional, combustible cigarettes.

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“It recommended that smokers who cannot or will not quit smoking tobacco try e-cigarettes and expressed great concern that the public perceived the two products as posing equal risks,” write Fairchild and her colleagues.

The PHE report also emphasized that e-cigarettes are a relatively low-cost tool for reducing smoking and, thus, could help address the challenge of health inequalities related to smoking and helping people quit.

Not all medical officials in the U.K. agreed, but 12 prominent public health organizations, including Cancer Research U.K. and the British Lung Foundation, issued a press release in support of the PHE report when it came under attack.

Even the influential British anti-tobacco organization Action on Smoking and Health (ASH) applauded the PHE’s report, Fairchild and her co-authors note.

That wasn’t so unexpected, however. A year earlier, the chair of ASH had told a reporter for the Guardian newspaper that “it would be a public health tragedy if smokers were discouraged from switching to electronic cigarettes and vapers were encouraged to go back to smoking because they don’t understand that vaping is a lot less harmful than smoking. That really would cost lives.”

A consistent approach

“As dramatic as the report’s recommendations appear to be, they build on the United Kingdom’s long-standing commitment to harm reduction,” write Fairchild and her colleagues.

As far back as 1926, they point out, England’s Ministry of Health had not only concluded that drug addiction was an illness that needed to be treated by physicians, but it had also recommended that low doses of drugs be used during treatment to prevent withdrawal symptoms. And when the AIDS epidemic came to the U.K. in the 1980s, government health officials advocated for programs that encouraged safer drug practices among injection-drug users.

This harm-reduction approach has been similarly applied over the years in the U.K. to tobacco products. A decade before the PHE report, the Tobacco Advisory Group of the Royal College of Physicians issued its own report, in which it argued “that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved.”

Focusing on abstinence

In the United States, however, public health officials have overwhelmingly taken a “prohibitionist” approach to tobacco products, according to Fairchild and her colleagues.

“Tight narcotic regulation and refusal to provide narcotics to addicts as treatment or maintenance defined the U.S. posture for decades,” they explain. “… The Campaign for Tobacco-Free Kids — ASH’s U.S. equivalent and a powerful voice in anti-tobacco advocacy — has been unequivocal in its denunciations of e-cigarettes. Similarly, the Centers for Disease Control and Prevention hosted a Public Health Grand Rounds on e-cigarettes in which all five speakers focused on the possible health risks associated with e-cigarette use. None acknowledged a potential role for e-cigarettes in reducing the tobacco burden in marginalized populations or reducing health disparities. Given the tight focus on potential risks to children and nonsmokers, e-cigarettes were out of the question.”

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Still, one influential U.S. group came out last year in support of the PHE report, as Fairchild and her commentary co-authors point out: “In December 2015, the Truth Initiative (formerly the American Legacy Foundation) declared in an organizational position paper, ‘If prudently regulated, we believe ENDS [electronic nicotine delivery systems] hold promise as one means to move smokers to a less harmful product and reduce the devastating death and disease burden caused by combustible tobacco products.’”

No resolution yet in sight

This “across-the-pond” controversy, although now several years in the making, has really only begun to heat up.

“Will England change the international conversation about e-cigarettes?” asks Fairchild and her colleagues.

“The answer,” they stress, “will depend, in part, on what the evolving evidence suggests, and it may take years before the answers are definitive. In the end, the sorts of policies that are implemented will depend on whether whoever dominates the debate views harm reduction as opportunity or anathema.”

FYI: The “Perspectives” commentary can be downloaded and viewed in its entirety at the NEJM website.