Challenging the American Consensus on E-Cigarettes: The English Raise the Ante

To e-puff or not to e-puff: that is the question. Public Health England (PHE), a governmental body the equivalent of our Centers for Disease Control and Prevention (CDC), recently released an evidence review claiming that e-cigarettes are 95 percent less harmful to health than combustible cigarettes. In recommending that smokers who cannot or will not quit cigarettes try e-cigarettes, PHE takes a position on the opposite side of the aisle from the U.S., where many prominent tobacco control advocates, public health officials, and policymakers are critical of e-cigarettes. Viewpoints in the U.S. range most commonly from unequivocally denouncing e-cigarettes and linking them with adverse health risks to a far less frequent willingness to consider these devices to hold promise for moving tobacco smokers to a less harmful product, a belief held by the Truth Initiative (formerly the American Legacy Foundation).
 
In a new, thought-provoking “Perspective” in the New England Journal of Medicine, the debate continues. Researchers from Columbia University’s Mailman School of Public Health draw on the history of harm reduction in the UK and U.S., comparing the UK’s conclusion in 1926 that drug addiction was an illness that should be treated by physicians with safe drug practices to the very different U.S. stance of refusing drugs to addicts as a treatment practice. Comparisons like these led the researchers to the question: Do electronic cigarettes work against reducing tobacco smoking or offer the possibility of minimizing harm for those who just cannot quit tobacco cigarettes?
 
When the PHE report was released, the authors were immediately chastised for recommending that smokers try e-cigarettes. In “E-cigarettes: Public Health England’s evidence-based confusion,” the editors of The Lancet seized on the methodological limits of one of the many studies on which the review had relied. They concluded, “PHE claims that it protects and improves the nation’s health and well-being…. On this occasion, it has fallen short of its mission.” In The British Medical Journal, academic experts asserted that PHE had failed to meet the most basic evidentiary standard of public health policy.
 
Nevertheless, 12 prominent UK public health organizations supported the PHE’s report and agreed that switching to the nearly harmless e-cigarettes with the support of a smoking cessation service could assist smokers to quit tobacco altogether. According to estimates, as many as 2.6 million adults in Britain currently use e-cigarettes.
 
In the U.S., opinion is more uniform. The organization Campaign for Tobacco-Free Kids explicitly denounces e-cigarettes, and the CDC warns that smokeless cigarettes may be associated with health risks. This is at the same time that the chairman of the UK anti-tobacco organization Action on Smoking and Health said it would be “a public health tragedy if smokers were discouraged from switching to electronic cigarettes.”  
 
The emergence of e-cigarettes continues to evoke a fierce debate in the public health community, both domestically and abroad. So where do we go from here? The Perspective titled, “Evidence, Policy, and E-Cigarettes—Will England Reframe the Debate?” is coauthored by Sharon Green, MPH, Department of Sociomedical Sciences; and Ronald Bayer, PhD, and Amy Fairchild, PhD, professors of Sociomedical Sciences and co-directors of the Center for the History and Ethics of Public Health at Columbia University’s Mailman School of Public Health.  An audio interview with Dr. Fairchild is available at NEJM.org

The research was funded by the Robert Wood Johnson Foundation.