Let’s start with the good news….

Another response to Welsh Health Minister Mark Drakeford and his lack of evidence.

Let’s start with the good news. There are at least 100,000 vapers in Wales, which has mainly grown over the last 2 years. A vaper is simply someone who uses an e-cigarette. These people are now smoking fewer or no cigarettes. With 5,000 people dying every year in Wales from smoking related illnesses according to the Welsh NHS, this should be a cause for celebration not concern.

Recently published figures from the Welsh Health Survey has shown a fall of 2% in the proportion of people who smoke. Given that the Welsh population currently sits at around 3.5 million, 2% of that number works out at approximately 70,000. Given that there are 100,000 vapers in Wales, could not a large proportion of that smoking reduction be attributed to the rise of e-cigarette use ?

Now onto the bad news: the Welsh Government’s proposal to ban the use of e-cigarettes in enclosed public spaces, substantially enclosed public places, and places of work.

Health Minister Mr Drakeford, whilst recognising the benefits of e-cigarettes stated in his recent article that he has a number of concerns regarding their use in public. These concerns include e-cigarettes undermining the current smoking ban, contributing to a renormalisation of smoking, being a gateway product, and being targeted at children.

These concerns would be perfectly valid if they had any foundation or evidence base, but they do not. In fact the available evidence points to the contrary.

The Chartered Institute of Environmental Health stated that there is a 99.7 per cent compliance rate with the smoking ban[1], and there is no evidence to support the idea that the use of e-cigarettes in public is undermining this. Yes, some companies have introduced a vaping ban, but we are seeing a growing number of such companies reversing these bans. Recently, Cambridgeshire Police, following a review of “health fears”, decided to allow their officers to vape at work[2].

Leading Pubco Enterprise Inns have recently reversed their ban on e-cigarettes in their licensed premises. In a further move, Enterprise Inns has signed a new supply deal for its tenants to stock and sell Nicolites e-cigarettes which will form part of their open welcome to the vaping community.

There is no evidence that e-cigarette use in public leads to a renormalisation of smoking either. Professor Robert West, Professor of Health Psychology and Director of Tobacco Studies at University College London’s Department of Epidemiology and Public Health, following his latest research concluded:“Despite claims that electronic cigarettes risk re-normalising smoking, we found no evidence to support this.”[3]

When it comes to concerns about e-cigarettes being a gateway product and their use amongst children, of course experts need to monitor this, but all the evidence to date shows that we have nothing to worry about.

To justify his concerns, Mr Drakeford cited a study produced by John Moores University, yet this study actually concludes that ‘Overall seven out of eight young people had never accessed e-cigarettes’. Recent research produced by ASH also shows that e-cigarettes are not a gateway to smoking[4]. Furthermore, the survey found that regular use of e-cigarettes amongst children is rare and confined almost entirely to those who are currently or have previously smoked[5]. Research undertaken by Queen Mary University[6] found that a child trying a tobacco cigarette for the first time is 50 per cent likely to become a regular smoker. The same research found no evidence that a child trying an e-cigarette for the first time goes on to become a regular vaper. Thankfully the Welsh Government has introduced a ban on the sale of e-cigarettes to under 18s, a move that we fully support!

The ban on smoking in enclosed public places was introduced to benefit the health of non-smokers whose health was put at risk as a result of being in close proximity to smokers. Therefore any proposal to include e-cigarettes within this ban must also be to protect the health of non-vapers.

Is passive vaping dangerous? A major scientific study undertaken by Dr Konstantinos Farsalinos (Researcher, Onassis Cardiac Surgery Centre, Greece, University Hospital Gathuisberg, Belgium) and Professor Riccardo Polosa (Director of the Institute for Internal Medicine and Clinical Immunology of the University of Catania, Italy) concluded that the ‘effects of e-cigarette use on by-standers are minimal compared with conventional cigarettes.’[7]

In his article, Mr Drakeford stated that this proposal was rather minor and that it would have no impact on the e-cigarette industry or vapers. However, in Spain where a ban on the use of e-cigarettes in public places has been introduced, there has been a 70 per cent fall in the number of vapers and a 60 per cent decrease in the number of vaping shops[8]. People that had made the switch to e-cigarettes are unfortunately now smoking again.

If the Welsh Government succeeds in banning e-cigarettes in public places, they will be forcing vapers to vape alongside smokers and exposing them to the dangers of second-hand smoke. We are in contact with vapers on a daily basis and many have said such a ban would simply force them back to smoking. Is this really what the Welsh Government wants?

A recent open letter to the World Health Organisation was signed by no less than 53 of the leading scientists in nicotine and public health policy. The open letter appealed directly the WHO to adopt a positive, proportionate and rational approach to products that provide very low-risk alternatives to smoking – products such as e-cigarettes. It called upon the WHO to recognise that this approach, tobacco harm reduction, as an important part of the solution offering great promise for public health, and not part of the problem.

In a recent BBC[9] poll 62 per cent of the public said e-cigarettes should not be banned in public and Professor John Briton from the Royal College of Physicians has said: “If all the smokers in Britain stopped smoking cigarettes and started using e-cigarettes we would save five million deaths in people who are alive today. It’s a massive potential public health prize.”[10]

The rise of e-cigarette sales is directly contributing to a decline in cigarettes sales. In the words of Professor Robert West: “What is the problem that requires further regulation?”[11] What public health gain does the Welsh Government hope to achieve with this proposal?

With a ban on the advertising of e-cigarettes soon to be introduced, following the passing of the Tobacco Products Directive, where are smokers to find out about e-cigarettes, particularly if they are banned in public? Smokers need to see people using e-cigarettes in public, they need to be able to go up and speak to e-cigarette users so that they can find out further information and then hopefully make the switch to a safer alternative.

In its approach the Welsh Government are going against the precautionary principle as it was originally intended, they are trying to mitigate for a risk that has yet to be proven and in doing so may do more harm than good.

 

 

[1] Meeting of the All-Party Groups on Smoking and Health, Pharmacy, and Heart Disease 10 June 2014

[2] http://www.cambridge-news.co.uk/Cambridge/Police-in-Cambridgeshire-can-smoke-e-cigarettes-after-health-review-but-they-are-banned-on-our-trains-20130821131920.htm

[3] http://metro.co.uk/2014/04/27/e-cigs-cleared-of-being-route-into-smoking-4710734/

[4] http://metro.co.uk/2014/04/27/e-cigs-cleared-of-being-route-into-smoking-4710734/

[5] http://www.ash.org.uk/files/documents/ASH_891.pdf

[6] Research undertaken by Professor Peter Hajek, Director of the Tobacco Dependence Research Unit at Queen Mary University of London

[7] Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review:

Konstantinos E. Farsalinos and Riccardo Polosa

published online 13 February 2014 Therapeutic Advances in Drug Safety

[8] http://www.thinkspain.com/news-spain/24345/e-cigarette-sales-in-spain-drop-by-70-per-cent

[9] http://www.bbc.co.uk/news/health-24909648

[10] The Independent Newspaper, 29 March 2013

[11] Professor Robert West speaking at the E-cigarette Summit, The Royal Society, London on the 12th of November 2013.

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With all due respect Mr Drakeford….

Dear Mr Drakeford,

We would like to thank you for taking the time to attend and listen to the debate on Welsh Government proposals for a ban on the use of e-cigarettes in enclosed public spaces, substantially enclosed public places, and places of work in Wales. In your response to the debate you raised a number of issues that cause us concern.

You stated e-cigarettes were renormalising smoking and undermining the ban on smoking in public places.

On both points you were unable to provide any evidence that e-cigarettes were either renormalising smoking or undermining the ban on smoking in public places. However, Professor Robert West, Professor of health psychology and director of tobacco studies at University College London’s department of epidemiology and public health, following his latest research concluded:“Despite claims that electronic cigarettes risk re-normalising smoking, we found no evidence to support this.”[1]

You stated e-cigarettes act as a gateway to smoking tobacco cigarettes and that this was a particular problem for children who are using e-cigarettes in growing numbers. You stated that many of these children were not currently or previous smokers of tobacco cigarettes and were attracted by flavoured e-liquid.

To justify this claim you cited a study produced by John Moores University entitled ‘Young People’s Perceptions and Experiences of Electronic Cigarettes’. You gave the impression that this report stated that as a direct result of targeted advertising by e-cigarette manufacturers, large numbers of children, who had not previously smoked tobacco cigarettes, were now using e-cigarettes and then going on to smoke tobacco cigarettes. What the report actually states is that ‘Overall seven out of eight young people had never accessed e-cigarettes’. The report goes on to say, ‘Despite widespread advertising of e-cigarette brands in print, visual and social media, the majority of participants reported that they had not seen any advertising for e-cigarettes and showed a lack of awareness of advertising and marketing strategies and approaches’.

What we do know from recent research produced by ASH is that e-cigarettes are not a gateway to smoking. Deborah Arnott, Chief Executive of ASH, said: “There is no evidence from our research that e-cigarettes are acting as a gateway into smoking.”[2] Furthermore, this same survey demonstrated that children are not using e-cigarettes. The survey found that regular use of e-cigarettes amongst children and young people is rare and is confined almost entirely to those who currently or have previously smoked[3]. Research by ASH[4] found that 96 per cent of 14 year olds had never used an e-cigarette, 90 per cent of 15 year olds had never used an e-cigarette, 90 per cent of 16 year olds had never used an e-cigarette, and 91 per cent of 17 year olds had never used an e-cigarette.

Research undertaken by Queen Mary University in London[5] found that a child trying a tobacco cigarette for the first time is 50 per cent likely to become a regular smoker. The same research found no evidence that a child trying an e-cigarette for the first time goes on to become a regular vaper.

Evidence produced by a variety of organisations including ASH and the American Cancer Society (ACS) clearly shows that flavours do not entice non-smokers to use e-cigarettes either. Researchers from the ACS[6] found that flavours did not increase the attractiveness of e-cigarettes to teenagers. Rather, “Even after controlling for other statistically significant correlates, the odds of a smoker being willing to try an e-cigarette were 10 times those of a non-smoker.” Tobacco cigarettes are the gateway to tobacco smoking, not e-cigarettes.

Finally, there is no evidence to support your claim that e-cigarettes are used in significant numbers by people who have never smoked. ASH concluded that, ‘E-cigarettes are used by both smokers and ex-smokers, but there is little evidence of use by those who have never smoked or by children.’[7] In fact, recent research showed that just 0.1 per cent of e-cigarette users had never smoked tobacco cigarettes previously[8].

You stated that nicotine is addictive and highly dangerous.

Yes nicotine is addictive but that does not mean it is dangerous. Caffeine is addictive, is that dangerous? The nicotine contained in e-cigarettes is the same pharmaceutical grade nicotine used in NRT products (some of which are inhaled). As Professor Robert West said: “E-cigarettes are about as safe as you can get. We know about the health risks of nicotine. Nicotine is not what kills you when you smoke tobacco. E-cigarettes are probably about as safe as drinking coffee.”[9]

Professor Peter Hajek, Director of the Tobacco Dependence Research Unit at Queen Mary University of London, said: “E-cigarettes are orders of magnitudes safer than cigarettes because they do not release smoke which contains toxins which are responsible for heart disease, lung disease, and cancer.”[10] The NHS has also concluded that e-cigarettes are 1,000 times safer than tobacco cigarettes[11]. You should also note that many vapers use an e-cigarette that does not contain any nicotine.

You stated e-cigarettes are no more effective than nicotine patches in helping people quit smoking.

Many vapers have tried numerous times to quit smoking using conventional nicotine replacement therapies, which have a 90 per cent failure rate, and have failed, however with e-cigarettes they have all cut down their smoking or stopped completely. Professor Robert West said: “We found that those using the e-cigarette were about 60 per cent more likely still not to be smoking than those using the licensed product or nothing at all.”[12] E-cigarettes are however not some form of more effective nicotine replacement therapy, they are totally different and need to be regulated accordingly.

A key reason for calling for a ban on the use of e-cigarettes in public places would be if there was a problem with passive vaping. We note that you did not raise this issue in your response. Could this be because there is no evidence that passive vaping is a problem? In fact a major scientific study undertaken by Dr Konstantinos Farsalinos and Professor Riccardo Polosa concluded that the “effects of e-cigarette use on by standers are minimal compared with conventional cigarettes.”[13]

You also failed to raise the issue of what support your proposal has amongst the public at large. A recent poll by the BBC[14] found that 75 per cent of the public would be happy if their friends or family switched from smoking tobacco cigarettes to using e-cigarettes, and 62 per cent of the public said that e-cigarettes should not be banned in public.

On the specific case of banning the use of e-cigarettes in the work place, you may like to know that a number of pubs that had previously introduced a ban have now gone on to reverse the ban as new evidence has emerged. You may also be interested to know that Cambridgeshire Police, following a review of “health fears”, will allow their officers to vape at work[15]. We are confident that as the evidence continues to mount, a growing number of businesses and organisations will reverse their current bans. Far from leading on this issue, it would seem that this Welsh Government proposal would actually be a backwards step if it were implemented.

Smoking tobacco cigarettes kills over 5,000 people in Wales every year. We know that nicotine replacement therapies with their 90 per cent failure rate do not work. We also know that e-cigarettes are a safer alternative to tobacco cigarettes and that they enjoy widespread popularity amongst the public at large. You must see that it is clearly better for some to use an e-cigarette rather than a tobacco cigarette. As Professor John Briton from the Royal College of Physicians said: “If all the smokers in Britain stopped smoking cigarettes and started using e-cigarettes we would save five million deaths in people who are alive today. It’s a massive potential public health prize.”[16]

The rise of e-cigarette sales is directly contributing to a decline in tobacco cigarettes sales. In the words of Professor Robert West: “What is the problem that requires further regulation?”[17] What public health gain does the Welsh Government hope to achieve by banning the use of e-cigarettes in public? You failed to answer this question in your response.

With a ban on the advertising and promotion of e-cigarettes soon to be introduced, following the passing of the Tobacco Products Directive, where are smokers to find out about e-cigarettes, particularly if they are banned in public places? Smokers need to see people using e-cigarettes in public, they need to be able to go up and speak to e-cigarette users so that they can find out further information and then hopefully make the switch to a safer alternative.

Quitting smoking or cutting down on smoking is one of the most difficult things an individual can do. If the Welsh Government succeeded in having e-cigarettes banned in public places they will be forcing vapers to vape alongside smokers. We are in contact with vapers on a daily basis and many have said such a ban will simply force them back to smoking, is this really what you want? Surely you would rather people used e-cigarettes rather than tobacco cigarettes? Professor Antoine Flahault, Dean of EHESP School of Public Health (Ecole des Hautes Etudes en Santé Publique), concluded: “It is better to have an addiction to a behavior that is not harmful than to have an addiction to a behavior that kills you.”[18]

Yes e-cigarettes are relatively new, but new research, including long term studies, is being produced on a regular basis. Much of the recent research has rendered the arguments behind the Tobacco Products Directive redundant and out of date, and caused some policy makers to call for a rethink.

In its approach the Welsh Government are going against the precautionary principle as it was originally intended, you are trying to mitigate for a risk that has yet to be proven and in doing so may do more harm than good. As Professor Robert West said: “We have such a massive opportunity here. It would be a shame if we let it slip away by being overly cautious.” Professor Gerry Stimson, London School of Hygiene and Tropical Medicine and the National Institute for Health and Clinical Excellence, concluded: “It would be an appalling paradox if regulators, in the name of safety, ended up tipping the balance back in favour of cigarettes.”[19]

In your comments yesterday you were unable to provide one single piece of evidence for any public health gain arising from the Welsh Government’s proposals. We know from the evidence we have laid out in this letter, the experts we have consulted, and the vapers that we are in daily contact with, that should you succeed in implementing this ban that fewer people will make the switch from tobacco cigarettes to e-cigarettes. We therefore hope that following the consultation you will conclude that for the good of harm reduction there is no need to implement a ban on the use of e-cigarettes in enclosed public spaces, substantially enclosed public places, and places of work in Wales.

Yours sincerely

Save e cigs.

CC

All members of the Welsh Assembly

All Welsh members of the House of Commons

 

[1] http://metro.co.uk/2014/04/27/e-cigs-cleared-of-being-route-into-smoking-4710734/

[2] http://metro.co.uk/2014/04/27/e-cigs-cleared-of-being-route-into-smoking-4710734/

[3] http://www.ash.org.uk/files/documents/ASH_891.pdf

[4] http://www.ash.org.uk/files/documents/ASH_891.pdf

[5] Research undertaken by Professor Peter Hajek, Director of the Tobacco Dependence Research Unit at Queen Mary University of London

[6] http://www.jahonline.org/article/S1054-139X(12)00409-0/fulltext

[7] http://ash.org.uk/files/documents/ASH_715.pdf

[8] http://www.theguardian.com/society/2014/apr/28/e-cigarette-users-triple-ash-survey

[9] The Guardian Newspaper, 05 June 2013

[10] http://www.bbc.co.uk/news/health-27161965

[11] http://www.spectator.co.uk/features/9197731/vape-alarm/

[12] Study carried out on 5,000 smokers, by Professor Robert West looking at the success rate of different methods to stop smoking: nicotine gum, nicotine patches, nothing, or e-cigarettes. Reported on BBC Breakfast 28 April 2014

[13] Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review:

Konstantinos E. Farsalinos and Riccardo Polosa

published online 13 February 2014 Therapeutic Advances in Drug Safety

[14] http://www.bbc.co.uk/news/health-24909648

[15] http://www.cambridge-news.co.uk/Cambridge/Police-in-Cambridgeshire-can-smoke-e-cigarettes-after-health-review-but-they-are-banned-on-our-trains-20130821131920.htm

[16] The Independent Newspaper, 29 March 2013

[17] Professor Robert West speaking at the E-cigarette Summit, The Royal Society, London on the 12th of November 2013.

[18] http://www.youtube.com/watch?v=wTHGsTPklY4&list=UUAy2QbmqgmTUJ–CoK5J3xA

[19] Open letter to ENVI Committee members form Professor Gerry Stimson 22 April 2013