As part of a debate I was involved with at the Conservative conference this week on public health policy and e-cigarette legislation, I demonstrated an e-cigarette to the audience by inhaling on it. Judging from the reaction of some of them you would have thought I had just rolled up my sleeve and injected heroin, and this is one of the problems with public perception of this form of nicotine replacement therapy. Without being driven by doctors e-cigarettes have become the public’s preferred choice of nicotine replacement, with an estimated 2.9 million people now using them, up from 700,000 in 2012 when figures were first collected.
The basic point remains that smoking continues to be the single biggest cause of preventable early death and illness in England, with some 100,000 deaths in the UK attributable to smoking each year despite the rate of smoking having halved in the last 50 years. Even on the most optimistic grounds, and including implementing policies currently under consideration, this prevalence is unlikely to reduce to 10 per cent by 2025.
As a GP committed to reducing morbidity and mortality in smokers, I have no doubt that the NHS and recent smoking cessation campaigns have been very effective at helping the ‘soft underbelly’ of smokers quit. This is obviously hugely encouraging, but we face a tougher challenge with smokers who have either been unable to quit or who choose not to. I now believe this means that our views on smoking cessation need to widen to include harm reduction as a valid end-point rather than the absolute cessation of cigarettes or nicotine-related products.
It is vital to remember here that it is not nicotine that kills smokers – after all, medicinal nicotine has a minimal effect on the body, usually consisting of a temporary small rise in pulse and blood pressure – but the 7,000 or so chemicals inhaled in tobacco smoke. These include niceties such as arsenic, cyanide, lead and ammonia as well as almost 70 potential cancer-causing chemicals, so preventing smokers from inhaling smoke is a key aim of health professionals. Smoking one cigarette takes around 11 minutes off your life so smoking 20 a day for a week loses a day of life expectancy.
I use the term ‘harm reduction’ to mean decreasing the burden of death and disease, without completely eliminating nicotine use. In 2007 the Royal College of Physicians stated that ‘if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lived could be saved’.
Licensed NRT products include transdermal patches, tablets and lozenges, inhalators, gum and nasal or mouth sprays. In practice however I have found that these sometimes fail to help smokers quit because they are not delivering nicotine in the same way that cigarettes do, including not being able to address the sensory cues and rituals so often associated with smoking. This may in part explain the dramatic rise in the use of e-cigarettes by smokers trying to quit because they offer smokers a similar experience to their normal habit. In my surgery, increasing numbers of smokers are telling me they are trying these as an aid to cutting down smoking or quitting, and ignoring this phenomenon is not helpful.
For the first time, there are more ex-smokers (1.5 million) who use e-cigarettes than current smokers (1.3 million) and the main reason given by ex-smokers who are currently vaping is to help prevent them returning to their cigarettes. Despite their phenomenal increase in popularity though, public perceptions of harm from e-cigarettes remains inaccurate with only 13 per cent of people accurately understanding that e-cigarettes are considerably safer than smoking, and with just under a third of smokers knowing that nicotine replacement therapy in general is much less harmful than smoking.
60 years after the seminal publication of smoking on health by Doll and Hill, we must continue to strive to reduce the impact of cigarettes on the health of the country. Ignoring the rise in e-cigarette use among smokers is not an option in my view, and I would have no qualms whatsoever about being able to prescribe regulated e-cigarettes on prescription. It may be nicotine that makes it hard for smokers to quit, but it is smoke and tar that puts them in the ground.