K. Farsalinos, August 22nd to Hong Kong

Recipient: The Legislative Council of The Hong Kong Special Administrative Region

Date: June 22, 2015

Legislative proposals to strengthen tobacco control in Hong Kong

Dear Members of the Panel on Health Services,

I am writing this letter commenting on the proposal to ban electronic cigarettes that will be discussed during the special meeting on “Legislative proposals to strengthen tobacco control”.

Electronic cigarettes are the newest addition in the field of tobacco harm reduction, a concept of reducing morbidity and mortality by providing alternative to smoking products with far lower risk potential. This concept was derived from the admission that smokers smoke for nicotine (and the psycho-behavioral experience derived from the act of smoking) but die from tar (i.e. the combustion products which the smokers inhale).

Smoking cessation is a very difficult task. Current medications consist of nicotine replacement therapies (NRT – mostly in the form of gums and patches), oral medications (bupropion and varenicline) and psychological support. The efficacy of these medicinal products is disappointing. In randomized controlled trials, NRTs have a 1-year success rate of approximately7%, which is much less when psychological support is not included [1]. In cohort studies of real-world quit attempts, over-the-counter use NRT in self-initiated quit attempts confers no advantage over stopping without any aid [2]. The efficacy of oral medications is lower than 20% even in well-designed medical studies [3], while in every-day clinical practice it is considerably lower [4]. Moreover, oral medications are hindered by serious adverse neuropsychiatric effects [5]. As a result, the majority of smokers are unable to quit smoking with currently available methods. Additionally, those who want to continue experiencing the positive effects of the smoking habit are unlikely to use any kind of medication since these do not substitute the pleasure perceived from smoking.

In that context, it is paradoxical to allow accessibility and use of the most harmful form of nicotine intake (tobacco cigarettes) while banning the use of a much safer alternative (electronic cigarettes). There is substantial evidence showing that electronic cigarettes are by far less harmful than smoking [6,7]. There is no tobacco and no combustion involved in electronic cigarette use. Additionally, the simulation of the behavioral aspects of smoking and the effective nicotine delivery, although severely criticized by parts of the tobacco control movement, are basically the main reasons for the efficacy of electronic cigarettes in substituting smoking. Thus, they are a perfect fit for tobacco harm reduction. Being a clinician and in close contact with smokers on a daily basis, it has been very motivating to see heavy smokers being able to quit within days after electronic cigarette use initiation. This has been a turning point in their life, accompanied by significant improvement in health status [8]. Electronic cigarettes have given the opportunity to these people to avoid the adverse long-term health effects of smoking. It should be emphasized that electronic cigarettes are used by smokers or former smokers, while use by youth or adult never smokers is negligible. Therefore, any benefit observed in the group of smokers will not be accompanied by harm from use by non-intended population (i.e. never smokers). The public health benefit of allowing the sales of electronic cigarettes has been observed in Great Britain, where there are 2.6 million electronic cigarette users, of which 1 million are now ex-smokers [9].

Instead of punishing smokers for the inability of medicine to develop effective smoking-cessation medications, it seems reasonable, and is also our ethical responsibility, to provide them with less harmful alternative products. This is not just an issue of personal choice; it is also about protecting their human right of being properly informed and making decisions that will protect personal health from the consequences derived from a harmful addictive habit. Smokers should be treated with sympathy and compassion. It is true that nicotine addictiveness may not be resolved by switching from tobacco cigarettes to electronic cigarette use. However, the main purpose of public health is to reduce harm and death. It is not our responsibility or right to dictate people not to use nicotine, considering that nicotine has minimal effects on smoking-related morbidity and mortality.

Electronic cigarettes represent a historical opportunity to make smoking obsolete. A decision to ban a less harmful form of nicotine intake while allowing the use of the most harmful product is paradoxical, inappropriate and damaging to public health. Any decision to ban electronic cigarettes is extreme, unsubstantiated by evidence and a sign of weakness. Moreover, it will have the unintended consequence of protecting tobacco cigarette sales, by removing from the market their strongest competitor. I am confident the regulators will make the correct decisions, protecting public health. I strongly support the need for appropriate and proportionate regulatory decisions that will ensure the availability of good quality products for consumers, while promoting evolution and development of new products. The European Union has been at the forefront of allowing the sales of electronic cigarettes while implementing rules to ensure quality and safety. Of note, the EU, as well as other regulatory agencies such as the US FDA, has correctly determined that electronic cigarettes should not be regulated as medications. This is extremely important considering that they are not used as therapeutic agents but to substitute a daily experience perceived from smoking with another experience. The huge variability of devices and liquid flavors characteristically satisfy the demand by the consumers and is associated with the consumers’ need to choose products based on personal preference [8,10,11].

It is of outmost importance for the regulators to be engaged in an open-minded debate, inviting scientists with vast experience on electronic cigarette research to present a balanced overview of the currently available evidence, with the main purpose of developing proper regulatory decisions to promote electronic cigarette use as an alternative to smoking while restricting use by never-smokers. I am certain that all scientists working in this field will be willing to contribute to this process. In any case, a decision to ban electronic cigarettes will represent nothing more than a great opportunity missed.

With respect

Dr Konstantinos Farsalinos

References

  1. Moore D, Aveyard P, Connock M, Wang D, Fry-Smith A, Barton P. Effectiveness and safety of nicotine replacement therapy assisted reduction to stop smoking: Systematic review and meta-analysis. BMJ 2009; 338: b1024.
  2. Kotz D, Brown J, West R. ‘Real-world’ effectiveness of smoking cessation treatments: A population study. Addiction 2014; 109: 491–499.
  3. Rigotti NA, Pipe A L, Benowitz NL, Arteaga C, Garza D, Tonstad S. Efficacy and safety of varenicline for smoking cessation in patients with cardio-vascular disease: A randomized trial. Circulation 2009; 121: 221–229.
  4. Casella G, Caponnetto P, Polosa R. Therapeutic advances in the treatment of nicotine addiction: Present and future. Ther Adv Chron Dis 2010; 1: 95–106.
  5. Hays JT, Ebbert JO. Adverse effects and tolerability of medications for the treatment of tobacco use and dependence. Drugs 2010; 70: 2357–2372.
  6. Farsalinos KE, Polosa R. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review. Ther Adv Drug Saf 2014; 5: 67-86.
  7. Hajek P, Etter JF, Benowitz N, Eissenberg T, McRobbie H. Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction 2014; 109: 1801-1810.
  8. Farsalinos KE, Romagna G, Tsiapras D, Kyrzopoulos S, Voudris V. Characteristics, perceived side effects and benefits of electronic cigarette use: a worldwide survey of more than 19,000 consumers. Int J Environ Res Public Health 2014; 11: 4356-4373.
  9. Action on Smoking and Health (ASH) UK. Use of electronic cigarettes (vapourisers) among adults in Great Britain, London, May 2015. Available at: http://www.ash.org.uk/files/documents/ASH_891.pdf
  10. Farsalinos KE, Romagna G, Tsiapras D, Kyrzopoulos S, Spyrou A, Voudris V. Impact of flavour variability on electronic cigarette use experience: an internet survey. Int J Environ Res Public Health 2013; 10: 7272-7282.
  11. Farsalinos KE, Stimson GV. Is there any legal and scientific basis for classifying electronic cigarettes as medications? Int J Drug Policy 2014; 25: 340-345.
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