Evidence, Policy, and E-Cigarettes — Will England Reframe the Debate? — NEJM

Because of the moralistic culture in which we live our tobacco control policy has been "just say no".  Blame is our approach to teen pregnancy and drug use.  Britian focuses on prevention. - gwc
Evidence, Policy, and E-Cigarettes — Will England Reframe the Debate? — NEJM

Sharon H. Green, M.P.H., Ronald Bayer, Ph.D., and Amy L. Fairchild, Ph.D., M.P.H.

N Engl J Med 2016; 374:1301-1303April 7, 2016DOI: 10.1056/NEJMp1601154

 Comments open through April 13, 2016

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Interview with Dr. Amy Fairchild on public health recommendations regarding electronic cigarettes in England and the United States. (10:53)

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Tobacco-control advocates have been embroiled in a multiyear controversy over whether electronic cigarettes threaten the goal of further reducing tobacco smoking or offer the possibility of minimizing harm for people who cannot or will not quit smoking conventional cigarettes. England and the United States have now staked out very different positions.

The international landscape was dramatically reshaped in August 2015, when Public Health England (PHE), an agency of England’s Department of Health, released a groundbreaking report, “E-cigarettes: an evidence update.” With its claim that e-cigarettes are 95% less harmful than combustible cigarettes, the report attracted headlines internationally. It recommended that smokers who cannot or will not quit smoking tobacco try e-cigarettes and expressed great concern that the public perceived the two products as posing equal risks. Strikingly, the report underscored e-cigarettes’ potential to address the challenge of health inequalities, a central mission of PHE, stating that these devices “potentially offer a wide reach, low-cost intervention to reduce smoking and improve health in these more deprived groups in society where smoking is elevated.”1

The report — written by tobacco-addiction researcher Ann McNeill of King’s College London — reflected the position on e-cigarettes that had been agreed to by the U.K. public health community. Yet the editors of the Lancet asserted that though PHE claims to protect the nation’s health and well-being, it has failed to do so with this report. Two public health scholars writing in the BMJalso denounced the report, seizing on the methodologic limitations of one of the many studies on which the evidence review had relied, underlining the potential conflicts of interests acknowledged in the paper, and roundly condemning PHE for failing to meet basic evidentiary standards. Invoking the precautionary principle, the authors asserted that e-cigarette proponents bore the burden of proving that these products are not harmful. In contrast, 12 prominent U.K. public health organizations, including Cancer Research U.K. and the British Lung Foundation, defended PHE. Their joint press release underscored a public health responsibility to encourage smokers to switch to e-cigarettes, perhaps with the help of local smoking-cessation programs.

As dramatic as the report’s recommendations appear to be, they built on the United Kingdom’s long-standing commitment to harm reduction. In 1926, the Ministry of Health’s Rolleston Committee concluded that drug addiction was an illness that should be treated by physicians, sometimes with a minimal dose of drugs in order to prevent withdrawal symptoms. When AIDS came to the United Kingdom in the 1980s, the first government report on human immunodeficiency virus (HIV) infection among injection-drug users encouraged safer drug practices. Meanwhile, the United States took a prohibitionist position. Tight narcotic regulation and refusal to provide narcotics to addicts as treatment or maintenance defined the U.S. posture for decades....

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