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Nicotine E-liquid Should Be Legalised

Published on 12/16/2017

Whenever I tell anyone I research e-cigarettes, they almost always have an opinion about them. Some will be vapers themselves, and those who are will almost without fail sing the praises of the device that finally helped them quit smoking. But often people who’ve never tried e-cigarettes will focus on the potential risks from using them, and in particular whether they’re likely to reintroduce smoking to a young generation who have been steadily shunning it in larger and larger numbers over recent decades. A particular fear is that young people will experiment with e-cigarettes and that this will be a gateway in to smoking, as well as fears around the harms from e-cigarettes themselves.

A recent detailed study of over 60,000 UK 11-16 year olds has found that young people who experiment with e-cigarettes are usually those who already smoke cigarettes, and even then experimentation mostly doesn’t translate to regular use. Not only that, but smoking rates among young people in the UK are still declining. Studies conducted to date investigating the gateway hypothesis that vaping leads to smoking have tended to look at whether having ever tried an e-cigarette predicts later smoking. But young people who experiment with e-cigarettes are going to be different from those who don’t in lots of other ways – maybe they’re just more keen to take risks, which would also increase the likelihood that they’d experiment with cigarettes too, regardless of whether they’d used e-cigarettes.

Although there are a small minority of young people who do begin to use e-cigarettes without previously being a smoker, as yet there’s little evidence that this then increases the risk of them becoming cigarette smokers. Add to this reports from Public Health England that have concluded e-cigarettes are 95% safer than smoking, and you might think that would be the end of the fear surrounding them.

But e-cigarettes have really divided the public health community, with researchers who have the common aim of reducing the levels of smoking and smoking-related harm suddenly finding themselves on opposite sides of the debate. This is concerning, and partly because in a relative dearth of research on the devices the same findings are being used by both sides to support and criticise e-cigarettes. And all this disagreement is playing out in the media, meaning an unclear picture of what we know (and don’t know) about e-cigarettes is being portrayed, with vapers feeling persecuted and people who have not yet tried to quit mistakenly believing that there’s no point in switching, as e-cigarettes might be just as harmful as smoking.

An unexpected consequence of this could be that it makes it harder to do the very research needed to elucidate longer-term effects of e-cigarettes. And this is something we’re experiencing as we try and recruit for our current study. We are conducting a research project funded by CRUK, where we’re collecting saliva samples from smokers, vapers and non-smokers. We’re looking at DNA methylation, a biological marker that influences gene expression. It’s been shown that smokers have a distinct methylation profile, in comparison to non-smokers, and it’s possible that these changes in methylation could be linked to the increased risk of harm from smoking – for example cancer risk. Even if the methylation changes don’t cause the increased risk, they could be a marker of it. We want to compare the patterns seen in smokers and non-smokers with those of e-cigarette users, potentially giving us some insight in to the long-term impact of vaping, without having to wait for time to elapse. Methylation changes happen relatively quickly as compared to the onset of chronic illnesses.

Part of the difficulty with this is that we know that smokers and ex-smokers have a distinct methylation pattern, and we don’t want this clouding any pattern from vaping, which means we need to recruit vapers who’ve never (or certainly only very rarely) smoked. And this is proving challenging for two reasons. Firstly, as borne out by the recent research, it’s very rare for people who’ve never smoked cigarettes to take up regular vaping. Yes, maybe they’ll experiment, but that doesn’t necessarily lead to an e-cigarette habit.

But on top of that, an unexpected problem has been the unwillingness of some in the vaping community to help us recruit. And they’re put off because of fears that whatever we find, the results will be used to paint a negative picture of vaping, and vapers, by people with an agenda to push. I don’t want to downplay the extreme helpfulness of plenty of people in the vaping community in helping us to recruit – thank you, you know who you are. But I was really disheartened to hear that for some, the misinformation and scaremongering around vaping has reached the point where they’re opting out of the research entirely. And after speaking to people directly about this, it’s hard to criticize their reasoning. We have also found that a number of e-cigarette retailers were resistant to putting up posters aiming to recruit people who’d never smoked, as they didn’t want to be seen to be promoting e-cigarette use in people who’d never smoked, which is again completely understandable and should be applauded.

What can we do about this? I hope that as more research is conducted, and we get clearer information on e-cigarettes ability to work as a smoking cessation tool, the disagreement around them will disappear. Until then, I hope that vapers continue to agree to take part in research so we can fully explore the potential of these devices, in particular those rare “unicorns” who vape but have never smoked, as they could be crucial to helping us understand the impact of vaping, as compared to smoking.

The number of smokers in Britain has reached its lowest point since records began in 1974, according to new data, while more than a million people say they are using e-cigarettes to help them quit smoking.

The latest data from the Office for National Statistics shows that 17.2% of adults in the UK smoked in 2015, down from 20.1% in 2010.

Smoking levels are highest in Scotland, at 19.1%, followed by Northern Ireland, where it is 19%, Wales on 18.1% and England on 16.9%. The numbers have been dropping fastest in recent years in Scotland and Wales. Among local authorities, Blackpool is the only one to feature consistently in the 10 heaviest smoking areas between 2012 and 2015. In 2015, 25.3% of adults in Blackpool smoked.

The data also shows that 2.3 million people were e-cigarette users in England, Scotland and Wales in 2015, about 4% of the population. Their survey also shows that 4 million more people describe themselves as former e-cigarette users. A further 2.6 million say they have tried them but not gone on to use them regularly.

Half of the 2.3 million who were current users of e-cigarettes at the time of the survey said they were doing it to quit smoking. A further 22% said they were vaping because it was less harmful than smoking. Only 10% said they chose to vape because it was cheaper than buying cigarettes. Others – 9% – said they used e-cigarettes mainly because they were permitted indoors.

The figures will bolster the arguments of those who believe e-cigarettes have a major role to play in ending the tobacco epidemic. The issue has been hugely controversial among public health doctors and campaigners, some of whom consider e-cigarettes to be a stalking horse for the tobacco industry which hopes to make smoking acceptable again and has invested in vaping.

The World Health Organisation has expressed concern over e-cigarettes, but Public Health England has said vaping may be 95% safer than smoking tobacco.

Half of current smokers say they have tried e-cigarettes, and 14.4% of current smokers also vape.

Some of the statistics suggest that it is often the heavier smokers who turn to e-cigarettes. Those who also vape smoke marginally more cigarettes per day on average than those who do not – 11.8 versus 11.3. Smokers who have given up on e-cigarettes smoke 12.2 per day versus 10.6 among those who have never used an e-cigarette. Smokers who have children at home are also more inclined to use e-cigarettes.

The ONS vaping data is from the opinions and lifestyle survey 2014-15 and relate just to Great Britain. The ONS figures on general smoking trends include northern Ireland.

Men are more likely to smoke – 19.3% do, compared with 15.3% of women. Smoking is most common in the 25-34 age group, where 23% smoked in 2015. It is least common in the over-65s, among whom 8.8% smoke. But the biggest decline since 2010 has been among the 18-24 year-olds, where it has dropped five percentage points to 20.7% in five years.

Figures for Great Britain also show that smokers have been cutting back on the numbers of cigarettes they consume. Average consumption is down to 11.3 cigarettes per day, the lowest number since 1974.

Deborah Arnott, chief executive of ASH said: “The decline in smoking is very encouraging and shows that strong tobacco control measures are working. However, the government can’t leave it to individual smokers to try to quit on their own. If the downward trend is to continue we urgently need a new tobacco control plan for England, and proper funding for public health and for mass media campaigns. That’s essential if the prime minister is to live up to her promise to tackle health and social inequality.”

 

Nicotine for vaping should be legalised in Australia: 40 international and Australian experts

Forty leading international and Australian academics and researchers including myself have written to the Therapeutics Goods Administration in support of an application to make low concentrations of nicotine available for use in electronic cigarettes (“vaping”).

In Australia, it is illegal to possess or use nicotine other than in tobacco or nicotine-replacement products, as nicotine is classified in the Poisons Standard as a Schedule 7 “dangerous poison”.

As the primary addictive component of tobacco smoke, nicotine is part of the problem. However, it may also be part of the solution. Using clean nicotine in e-cigarettes provides smokers with an alternative way of getting the nicotine to which they are addicted without the tobacco smoke that causes almost all of the harm from smoking.

As well as delivering nicotine, e-cigarettes replicate several important aspects of the “smoking experience”. This includes the hand-to-mouth movement and the sensory and social aspects of the habit that smokers so often miss when they try to quit.

The health effects of nicotine are relatively minor. It is not a carcinogen and does not cause respiratory disease. It has only relatively minor effects on the heart, such as short-lived rises in heart rate and blood pressure, constriction of coronary arteries and an increase in the contracting of the heart muscle.

Nicotine in pregnancy harms the baby’s developing brain and lungs and reduces growth. It is also harmful to the adolescent brain, delays wound healing and increases insulin resistance. There is some evidence in laboratory studies that nicotine may promote existing cancers.

However, when separated from the toxins in tobacco smoke and used in its pure form, there is little evidence of long-term harm from nicotine exposure in humans outside pregnancy and adolescence.

Research has found the health risks from vaping are unlikely to be more than 5% of the risk of smoking, and may well be substantially lower than this. As the vast majority of e-cigarette users are smokers or recent ex-smokers, this represents a huge health benefit for those who switch to vaping.

The effect of vaping on bystanders is also thought to be negligible. E-cigarettes release low levels of nicotine and minimal amounts of other chemicals into the ambient air. The expired vapour dissipates quickly with no significant health risks to bystanders.

Recent research has found nicotine is much less toxic than previously thought. Most cases of intentional overdose with nicotine solutions result in prompt vomiting and full recovery.

Similarly, accidental poisoning in children typically causes mild adverse effects. Serious outcomes are rare. Most child poisoning with nicotine can be prevented with common sense, childproof packaging and warning labels, just like other potentially toxic medicines and cleaning products found in the home.

Overseas experience has shown e-cigarettes are not a gateway to smoking for young people. Although adolescents are experimenting with e-cigarettes, regular use by non-smokers is rare. The great majority of adolescents use nicotine-free e-cigarettes.

In fact, the evidence suggests e-cigarettes are acting as an “exit gateway” and are displacing smoking. It is obviously better for young people not to use e-cigarettes, but vaping is preferable to smoking.

Smokers who are trying to reduce the health risks from smoking are using e-cigarettes almost exclusively as a safer alternative to combustible tobacco. After ten years of overseas’ experience, there is no evidence e-cigarettes are renormalising smoking, are undermining tobacco control or are being used to any significant extent for temporary, not permanent, abstinence (for example, in places where you can’t smoke).

Why nicotine should be legalised

Paradoxically, current Australian laws ban a less harmful form of nicotine intake (e-cigarettes) while allowing the widespread sale of the most lethal form of nicotine intake (tobacco cigarettes). In spite of the legal restrictions and difficulties of access, e-cigarette use has been growing rapidly in Australia.

Amending the Poisons Standard would allow smokers who are unable or unwilling to quit smoking to legally access low concentrations of nicotine for harm reduction. It is also legally used in nicotine-replacement therapies such as patches, so why not e-cigarettes?

Regulation under the Australian Consumer Law would improve product safety and quality, restrict sales to minors and ensure child-resistant containers and appropriate advertising. It would also eliminate the black market and the risks associated with it.

A recent study estimated over 6 million European Union citizens have used e-cigarettes to quit smoking. In the UK, 1.3 million ex-smokers are using an e-cigarette. Similarly, it is likely hundreds of thousands of Australians will quit smoking tobacco using e-cigarettes if nicotine is legally available.

After a full review of the evidence, the Royal College of Physicians (UK) recommended:

in the interests of public health, it is important to promote the use of e-cigarettes […] as widely as possible as a substitute for smoking.

New Zealand is working towards legalising nicotine-containing e-cigarettes. Australia needs to follow suit.

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