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

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

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.

“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.”

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.

Comments (3)

  1. Submitted by Steve Hoffman on 04/08/2016 - 02:01 pm.

    But they work!

    A dear friend of mine, who’s smoked for all the 50 years I’ve known her, would come to visit me, and at least once every hour she’d head out to the balcony for a cigarette. And then, having finished one, she’d smoke another. About four years ago she got an e-cigarette and hasn’t had a “real” one since. Now when she visits, about once every hour and a half she’ll absent-mindedly have one or two puffs on the e-cig (for which she doesn’t have to go outdoors, as it leaves no trace but a pleasant whiff of vanilla) but that’s it. She says her singing voice has regained about half an octave as a result. I don’t know why people in America fuss so about these — they’ve gotten at least three heavy smokers I know off nicotine altogether, and apparently painlessly.

  2. Submitted by Russell Booth on 04/08/2016 - 02:10 pm.

    American Puritan Ethics

    E-cigs are not regulated. They may be sold by demons who are out to get us, but they appear to be sold by honest businesspeople who see a market opening due to a technological advance. They are not good for you, but reducing harm by 95% (preliminary estimate) could be a very large public health boon.

    The US attitude seems to be that the years of research. mentioned in the last paragraph, must happen first before the government will treat e-cigs as if they are different from combusted tobacco.

    E-cigs are not regulated, but their purveyors claim they have 4 ingredients. Two are the same chemicals that are found as a base in asthma inhalers, which are a regulated medicine. There is of course nicotine which is about as harmful as caffeine, though addictive. The fourth ingredient is the health unknown: flavoring.

    My purveyors claim that the flavors used are FDA approved for consumption. It is not reasonable to claim that FDA scientists approved these flavoring agents not knowing that they would be heated. Humans have been cooking food for quite a long time.

    What I would like to know is: Which is more dangerous to the health of second-hand consumers – second hand vapor from being near someone using an e-cig, or fumes from somebody popping a popcorn pouch in the microwave?

    I am not a scientist but I would predict that a study would show that microwave popcorn vapors are at least 1000 times more hazardous to health than being in proximity to someone vaping.

  3. Submitted by Ray Schoch on 04/08/2016 - 10:42 pm.

    Agree and not

    I’m inclined to agree with the headline, and with the last sentence in Mr. Booth’s first paragraph.

    There’s nothing “healthy” about e-cigarettes, nor is there any research to show that human lungs benefit from frequent daily exposure to fumes from ANY source, Mr. Booth’s final sentence notwithstanding. That said, the approach in the U.K. seems eminently more sensible than what’s been adopted here. Moreover, since there’s ample proof, contemporary and historical, that prohibition simply does not work, it’s more than too bad that the standard, reflexive response in this country to the use of any substance for which there is not already a sizable legal market, is the one approach we know does not work: prohibition or abstinence.

    A life-long teetotaler, it’s my belief that we’d be much better off if any and all drugs were legal, taxed and regulated as the single most-abused drug in the country is taxed and regulated. That drug, of course, is alcohol. We tried to abolish it, and the attempt – much like the attempt over the past generation to abolish a host of other chemical substances we collectively refer to as “drugs” – was a cruel and dismal failure. In both cases, the most significant effect was to create a class of professional criminals who could, and did, make astonishing fortunes (not to mention killing thousands of people) peddling a substance, or a series of substances, that would otherwise be unremarkable if they were not illegal.

    We treat alcoholism as a health problem. We treat smoking and its associated nicotine addiction as a health problem, as well. Virtually all drug addictions ought to be treated as health problems, and one of the more useful ways to approach that is to minimize the harm done first, then work at diminishing the subject’s dependence on that substance.

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