Could cheap electronic cigarettes really be ‘perhaps the single most important public health breakthrough this century?’. Certainly Professor Robert West, one of the UK’s top experts in tobacco control seems to think so, and he is not alone with most of the experts in the field seeing huge opportunities ‘to legislate cigarettes out of existence’.
Alternative forms of taking nicotine instead of smoking a cigarette have been around for many years. NRT has been around for over 20 years, comes in many different forms and is widely available, and there are other ways of taking tobacco that have been around for hundreds of years, like chewing tobacco and snuff, which (though may not be totally safe) carry little risk.
But smokers are switching to ‘e-cigs’ in huge numbers. Some estimates indicate there are probably 1.3 million current users, up from 500,000 users just a year ago. Some will be mixing e-cigarette consumption with cigarette-smoking but most are eventually moving to just using a e-cigarette as their sole mode of getting their nicotine.
Every year the NHS Stop Smoking services currently help about 400,000 smokers to quit for a four-week period, but only one in four will become a long-term quitter and probably many of these smokers would have quit on their own. By that working, e-cigarettes may be delivering 10 times the number of extra quitters as the NHS.
E-cigarette smokers are still addicted to nicotine, but relatively speaking nicotine is a very safe drug. How many children do we find dead behind the bike shed after their first cigarette? Even in the worst case scenario - say, primary school children with no nicotine tolerance using the most potent of nicotine delivery devices, the cigarette, and egged on to the point of toxic overdose in the most in appropriate of environments- nicotine is very safe. And it’s very safe even long term. It is the products of combustion - tar and carbon monoxide - that makes a cigarette so dangerous in the long-term. But it is because smokers are still getting their nicotine hit that they are finding it easy to switch.
The other reason it’s easy to switch is cost - using e-cigarettes can be cheap - but then agaon, so can using cigarettes. A 20-a-day cigarette smoker would easily spend £50 a week feeding their addiction with shop-bought cigarettes, but most of my patients smoke using rolling tobacco, duty-free cigarettes or smuggled tobacco. A 20-a-day smoker using smuggled rolling tobacco may only be spending £8 a week. This is why we are probably not seeing patients from deprived areas qutting with the same success as patients from affluent area, and why we are not seeing much NRT substitution.
The new NICE guidance on harm-reduction approaches to smoking may, in theory, result in GPs prescribing NRT in an effort to reduce the damage of smoking, but does any of us really believe that of the UK’s 10-12million smokers, the NHS is going to start treating four or five million smokers with £500’s worth of NRT a year?
E-cigarettes, on the other hand, are a cheap alternative to cigarette smoking - and one financed by the ‘quitter’. Disposable e-cigarettes are what many smokers try before NRT, and at £30 a week for the equivalent of 20 a day, are cheaper than shop-bought cigarettes (although not much).
Smokers tend to quickly move to vaporisers or cartomisers (e-cigarettes with refill cartridges). These options cost around £10 to £20 for a starter kit and then £3 a week for nicotine ‘juice’ for the vaporisers or £7 a week for refills for the cartomisers.
But the MHRA has decided to regulate e-cigarettes. Some anti-smoking campaigners such as ASH have argued it should, but the decision was questionable. Nicotine in e-cigarettes maybe a drug but it isn’t being used as a medicine. The MHRA doesn’t regulate other drugs when they aren’t being used as medicines, for instance caffeine and alcohol.
After two years of deliberating, the MHRA decided they would regulate e-cigarettes in three years’ time - recognisign that we haven’t seen any significant safety problems with e-cigs, and that there would be huge public health gains if smokers switch to a safer alternative while e-cigarettes are unlicensed.
The regulation of e-cigarettes will inevitably drive up the costs and drive out the smaller players in the market - the big players will be the big pharmaceutical firms and big tobacco. At least one of the large tobacco firm is close to licensing an electronic cigarette with the MHRA.
The risk is that we make e-cigarettes more like NRT - safe but expensive. In three short years we may find the cheap e-cigarettes, that so many of our smokers are turning to now, will be banned.
The logical outcome of the NICE guidance, and the MHRA decision is the GPs may find themselves prescribing expensive NRT or electronic nicotine delivery systems for harm reduction at a huge cost to the NHS.
Our prescribing will at the same time increase the profits of tobacco firms selling expensive MHRA-licensed nicotine delivery systems.
Dr John Ashcroft is a GP in Derbyshire
