Dear Dr Pakenham-Walsh,
Thank you for maintaining a balanced discussion about e-cigarettes and driving towards the flashpoints for debate on this forum.
I would like to share a Letter to the Editor of the BMJ on this matter from Prof Glantz. This article explains why the Cochrane review should not be the only study informing our risk assessment of e-cigarettes. [1]
I will be liberal in pulling some of the salient points from the Letter because it can explain the reasons why better than I ever can:
- the Cochrane review in question formulates an opinion based on 6 studies (RCTs) from an original pool of over 70 documents;
- RCTs are designed to investigate the effectiveness of interventions provided in a clinical setting, a scenario in which e-cigarettes aren't typically given especially in countries where they are sold as consumer products, and;
- RCTs are not powered to provide insight on population-level impacts of interventions
It's worth noting that there is one study [2] in this systematic review which actually shows the superiority of varenicline over e-cigarettes.
Further, if the cessation claim is true, then it begs the question of why the UK's MHRA has still not granted authorizations for any e-cigarettes to be marketed as smoking cessation tools. [3]
I can only speculate, but I think people who have legitimately good intentions are pushing for e-cigarettes with the hope of finding a brand new solution to recalcitrant smokers. Some countries have already employed a wide variety of WHO FCTC interventions at the highest levels of implementation, but they are growing very impatient with smokers who simply cannot and will not stop. In this case, the WHO FCTC allows for countries to exceed its prescribed interventions (for example, instead of just graphic health warnings, a country can go for standardized packaging); the WHO FCTC only represents the basic minimum required of tobacco control interventions.
There is also the perfectly legitimate issue (especially in LMICs) of how expensive it can be to offer pharmacologic interventions for nicotine addiction. While returns on investment for quit-smoking health technologies (like varenicline) are generally favorable [4], this does not mean that LMICs would be automatically willing to pay for the up-front cost of these important interventions.
We do not discount the unique experiences of those, however few, who saw that e-cigarettes can help in their own smoking cessation journey. But personal experiences should not determine how entire nations should develop their quit-smoking strategies. To be informative, we need to be critical of the evidence and clearly communicate the size of effect and level of certainty that comes with every claim.
The burden of proof is with the tobacco industry. They have yet to demonstrate that their electronic smoking devices will yield a net positive effect on public health. Until then, the World Medical Association Resolution still stands [5], and we will be very cautious of any public health solutions that would come from their end.
Thank you.
Regards,
*Anton*
[1] Glantz S. Vaping helps adults quit smoking better than traditional methods, says Cochrane. BMJ 2022;379:o2782 doi: 10.1136/bmj.o2782
[2] Ioakeimidis N, Vlachopoulos C, Georgakopoulos C, et al. Smoking cessation rates with varenicline and electronic cigarettes in relapsed smokers with a history of acute coronary syndrome. European Heart Journal 2018;39(suppl_1) doi: 10.1093/eurheartj/ehy565.P1234
[3] ASH Scotland. (15 February 2023) Advertising regulator upholds health charity’s complaint against vaping company’s medicinal smoking cessation claims about e-cigarettes.
https://www.ashscotland.org.uk/news-and-events/news/2023/02/advertising-...
[4] Keating GM, Lyseng-Williamson KA. Varenicline: a pharmacoeconomic review of its use as an aid to smoking cessation. Pharmacoeconomics.
2010;28(3):231-54. doi: 10.2165/11204380-000000000-00000. PMID: 20108995.
[5] WMA Resolution on Implementation of the WHO Framework Convention on
Tobacco Control.
https://www.wma.net/policies-post/wma-resolution-on-implementation-of-th...
*Anton Javier*
FCTC Program Officer
Email: anton@seatca.org | Mobile: (+63)939 536 1355
Southeast Asia Tobacco Control Alliance
SEATCA.org <http://seatca.org/> I Twitter <https://twitter.com/SEATCAdotOrg>
I Instagram <https://www.instagram.com/seatca> I Facebook
<https://www.facebook.com/SEATCA/>
Help us put an end to the tobacco pandemic.
<https://seatca.org/seatca-donation/>
