By Alex Wodak
Having been involved in debates about harm reduction for 30 years, I can see many commonalities between the electronic cigarette debate and earlier debates about illicit drugs
A furious debate has been taking place in recent years over electronic cigarettes, and the debate can unfortunately become quite nasty and polarised. Public health practitioners who have fought together for decades are now often opposed.
Do electronic cigarettes (ECs) help smokers to quit? Are ECs as innocuous as their advocates claim? Is duplicitous and unscrupulous Big Tobacco cynically manipulating naïve EC supporters in their avaricious search for profits? Do ECs normalise smoking, thereby providing a gateway to increasing smoking? Have some EC advocates with murky links to the tobacco industry or pharmaceutical companies attempted to conceal these ties? Are ECs yet another in a long list of failed harm reduction attempts for tobacco?
These are among the most common questions debated and they are all important and legitimate questions. The problem is that they are not the most important questions. And in complex arguments, it is especially important to try to focus on the most important questions before trying to answer less important questions.
So what do I think are the most important questions? First, do ECs achieve their objectives – in other words, are they effective? Second, are they safe? Specifically, do they have some serious unintended negative consequences? Third, are they cost effective?
Are they effective?
The effectiveness of ECs depends on what we decide the objectives should be. In 2003, a pharmacist who had lost his father from a tobacco-related illness developed the first EC because he wanted to allow people to be able to continue consuming nicotine while avoiding a premature tobacco-related death or serious illness.
Tobacco control (TC) experts then added the objective of ECs as possible quitting agents and made this the key objective. As tobacco kills about two thirds of people who smoke cigarettes, it is easy to see why TC experts wanted to know whether or not ECs help smokers to quit. But surely the paramount objective for ECs should be the preservation of life and wellbeing. If ECs can also be shown to also assist smokers to quit, then achieving this objective should be regarded as a bonus.
Are they safe?
Probity issues are always important but they should not be allowed to distract us from the clear recognition that tobacco smoking is much more dangerous than vaping ECs. It is clear that ECs reduce some of the harm from tobacco smoking and that means they are effective.
Do ECs assist smokers to quit? This debate is not yet resolved but the evidence increasingly favours ECs being effective quitting agents. ECs have changed rapidly in the last 13 years and they are still doing so: this makes evaluation more difficult.
The debate about potential serious unintended negative consequences is also unresolved, but the arguments in favour of ECs having serious harms are looking increasingly threadbare.
Are they cost effective?
Cost effectiveness is especially important if public funding supports a policy or intervention. But smokers pay for their ECs and spend much less money on ECs than they do when smoking tobacco cigarettes.
As someone who has been involved in debates about harm reduction for three decades, I can see many commonalities between the EC debate and the earlier debates about harm reduction involving illicit drugs. These debates included needle syringe programs to stop HIV, methadone treatment for heroin dependence, heroin prescription treatment for heroin dependence and supervised drug consumption rooms. The harm reduction debates involving illicit drugs have delayed or stopped the adoption and implementation of interventions which we know saves lives, reduce HIV, decrease crime and save government funding. US Congress only approved federal funding for needle syringe programs to stop HIV in December 2015.
What are these commonalities? First, there is often confusion about objectives with secondary or tertiary objectives argued about furiously while the primary objective is ignored. In harm reduction, the paramount objective is always trying to reduce health, social and economic costs. Reducing drug consumption is often welcomed but is regarded as a bonus. Second, opponents of harm reduction often mount quite vicious ad hominem attacks and sometimes harm reduction supporters respond in kind. Third, opponents of harm reduction emphasise the quality and quantity gaps in research long after it is clear that there is sufficient evidence of reasonable quality to establish the effectiveness and safety of the intervention. Fourth, in the debate about illicit drugs and harm reduction three decades ago, harm reduction advocates were a minority ostracised by governments and the World Health Organisation.
In the debates about ECs, tobacco harm reduction advocates are a minority ostracised by governments and the World Health Organisation.
By any measure, tobacco smoking is by far the most important cause of drug-related deaths, disease and economic costs. This is true in Australia as it is globally. The substantial reduction in smoking and tobacco-related deaths and disease in Australia has been a public health and social triumph. Australians have also contributed greatly to this global battle, often fighting against the odds.
What is now needed in this EC debate? First, let’s try to agree on what are the most important questions we want answered about ECs and focus on these. And second, let’s try and bury all the ad hominem attacks which make a difficult debate even more difficult.