Open letter in the Norwegian Medical Association Journal December 2015

(Credit to MD PhD H O leira – document available online and translation by Atakan Befrits – any mistakes or misunderstandings shall be the responsibility of the translator alone – original here http://tidsskriftet.no/article/3429260)

Dec 8th 2015, Journal of the Norwegian Medical Association

Håkon Olov Leira, Postdoctoral Fellow, Norwegian University of Science and Technology, Trondheim Norway.

E-cigarettes are a good alternative to regular cigarettes, they can save many years of life lost and lost years of health, respectively. Sadly the Health Minister and central health communities want to restrict access.

I daily treat patients with severe smoking-related illness, provide advice on smoking cessation and reduction of cigarette consumption, and have been thrilled at the possibility of now being able to offer yet another means of smoke reduction, the e-cigarette. My impression from my own practice is that e-cigarettes and smokeless tobacco are more attractive for experienced smokers than patches and nicotine gum.

I wonder why there is such significant resistance from our Minister of Health, Public Health Agency and my experienced colleagues, to the idea of legalizing e-cigarettes. As recently as this summer the discussions in this journal portrayed e-cigarettes almost as a stimulus/equivalent to continued smoking (1, 2). The fight against tobacco is in this discussion turned into a fight against all nicotine, where we run the real risk of winning the battle but losing the war.

Years of life lost
Smoking causes heart attacks and strokes and is the main cause of lung cancer. In addition, smoking is a major cause of cancer of the mouth, pharynx, esophagus, stomach, pancreas and urinary tract. The Health Directorate (in Norway) estimates that smoking causes 8,000 deaths and 150 000 to 180 000 lost QALYs (Quality Adjusted Life Years) each year and that the social costs of smoking are up to 80 billion per year (3, 4). 4-5 billion cigarettes are smoked in Norway every year. That means every smoked cigarette corresponds to ca. 15 lost quality adjusted life minutes and consequently, an average a smoker has lost one quality-adjusted life year after just 6-7 years of smoking.

In an article in NRK Freedom in August 2014 the president of the Medical Association and director of the Institute of Public Health stated that we should phase out tobacco smoking by 2035 (5). In a follow-up article in Bergens Tidende, the Health Minister Høie is quoted as saying that he envisions that with active policy measures the smoking epidemic will be over by 2050 (6). If we multiply 150,000 lost QALYs and 8000 deaths per year with the NMA / NIPH 20 years or the health minister’s 35 years of waiting, it equates to roughly 150 000 to 200 000 deaths and 3 million to 4 million lost QALYs in the process.

E-cigarettes are just a little bit not Harmless
To put it very bluntly: It is the smoking of tobacco is dangerous, much less so tobacco itself. Tobacco is not entirely harmless, but cancer occurs primarily when organic material is heated to 700 ° C in cigarette and pulled into the lungs (7). Although tobacco has been in use for 500 years in Europe, lung cancer was a very rare form of cancer before the invention of the cigarette manufacturing machines in the late 1800s (8).

We now have excellent cigarette replacement products like gum, snus and e-cigarettes that all are virtually harmless compared to smoking. If available these alternatives should satisfy most needs except to roll your own cigarette or fill your briar pipe. So if we are not going to ban tobacco just yet, isn’t it time to immediately do everything we can to reduce actual smoking? Every cigarette counts.

Advice to the Minister of Health
E-cigarettes contain controllable chemical substances and can be made to, in principle, not contain any harmful substances beyond nicotine. Today, e-cigarettes are banned from being sold in this country and therefore unregulated. We risk leaving many to their own devices who may import dangerous products from rogue manufacturers. We should rather do as England did, who after a review of current research will allow e-cigarettes next year (9) (both as consumer product and as licensed cessation method).

According to the news the Norwegian government may come to allow a tasteless version of E-cigarettes next year, but these will unfortunately not appeal to the group who need it the most (10). Similar are already legally sold as as drugs, but without success,

My advice to the Minister of Health is therefore: Allow quality assured e-cigarettes and liquids with flavors and regulate emissions. Strongly encourage smokers to replace cigarettes with snus, e-cigarettes or nicotine pharmaceuticals. And finally: increase taxes on tobacco smoke and lower taxes on replacement products.

The goal for the health authorities should not be a tobacco-free society by 2050, but a cigarette and smoke free society much earlier than that.

Litteratur

1.	Sanner T, Grimsrud TK. E-sigaretter – til skade eller nytte? Tidsskr Nor Legeforen 2015; 135: 959 – 61. [PubMed]
2.	Folkehelseinstituttet. Bruk av e-sigaretter er ikke risikofritt. www.fhi.no/artikler/?id=114662(5.11.2015).
3.	Helsedirektoratet. Statistikk om røyking, bruk av snus og e-sigaretter.https://helsedirektoratet.no/folkehelse/tobakk-royk-og-snus/statistikk-om-royking-bruk-av-snus-og-e-sigaretter (10.9.2015).
4.	Helsedirektoratet. Samfunnsøkonomiske kostnader av røyking – En vurdering av metodikk og kostnadenes størrelsesorden.https://helsedirektoratet.no/Sider/Samfunns%C3%B8konomiske-kostnader-av-r%C3%B8yking-%E2%80%93-En-vurdering-av-metodikk-og-kostnadenes-st%C3%B8rrelsesorden.aspx (17.10.2015).
5.	Fem skritt for folkehelsen. Ytring. www.nrk.no/ytring/fem-skritt-for-folkehelsen-1.11881025(9.2.2015).
6.	Dyregrov S. Legeforeningen vil utfase salg av tobakk innen 2035. Bergens Tidende 6.10.2014. www.bt.no/sprek/Legeforeningen-vil-utfase-salg-av-tobakk-innen-2035–3206990.html (9.2.2015).
7.	Chemistry and toxicology of cigarette smoke and biomarkers of exposure and harm. I: How tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease: A report of the surgeon general. Atlanta, GA: Centers for Disease Control and Prevention, 2010.
8.	Adler I. Primary malignant growths of the lung and bronchi: a pathologic and clinical study. London: Longmans, Green and Company, 1912.
9.	Choices NHS. Some types of e-cigarettes to be regulated as medicines.www.nhs.uk/news/2013/06June/Pages/e-cigarettes-and-vaping.aspx
10.	NTB. Regjeringen vil behandle e-sigaretter som vanlig røyk.www.dn.no/nyheter/politikkSamfunn/2015/10/26/1320/regjeringen-vil-behandle-esigaretter-som-vanlig-ryk (5.11.2015).

Mottatt 17.10. 2015, første revisjon innsendt 20.11. 2015, godkjent 25.11. 2015. Redaktør: Martine Rostadmo.