In response to misleading attacks on Public Health England’s published reports estimating vaping to be at least 95% less harmful than smoking, Professor John Newton (Director of Health Improvement for PHE) and Martin Dockrell (Tobacco Control Programme Lead for PHE) recently published a blistering response in the American Journal of Public Health. That response (with footnotes excised) can be read below.
The continuing burden of tobacco-related harm worldwide requires action in relation to e-cigarettes despite imperfect evidence. England has been carefully developing and implementing an evidence-based approach to e-cigarettes for several years. It was disappointing, therefore, to see a poorly evidenced account of this work in a recent editorial by McKee.
The article that prompted the editorial is an interesting attempt to analyze two different reviews of a similar evidence base. Those involved in the English review by McNeill et al. have identified some inaccuracies in the account by US authors. The accompanying editorial, however, adds more significant layers of confusion by making unjustified observations about policymaking in England, greatly exaggerating the extent to which England is an outlier in relation to e-cigarettes, and misquoting a Public Health England (PHE) spokesman.
Tobacco policy in England is developed formally and set out by the government in its Tobacco Control Plan. E-cigarette policy is informed by the conclusions of a series of published evidence reviews commissioned from leading academics, not based on the opinion of a few individuals as implied in the editorial.
The overall claim of “English exceptionalism” fundamentally misrepresents the international position in relation to e-cigarettes. The United Kingdom’s strict regulations on e-cigarettes are, for example, very similar to those in all other European Union countries. Among countries with active tobacco control strategies, it is Australia (where the sale of nicotine-containing e-cigarettes is prohibited) and the United States (with no specific regulatory standards and few marketing restrictions in place on e-cigarettes) that now may be considered outliers. England was arguably ahead of other jurisdictions in implementing a harm reduction policy in relation to e-cigarettes, but countries like Canada, New Zealand, and France are now adopting very similar approaches. Some such as New Zealand go at least as far as England in promoting e-cigarettes as a cessation aid.
In the editorial, McKee states that PHE “takes a view that is so much at odds with those in the rest of the world” but fails to identify those views in any detail or show how they differ from the international consensus. PHE has always been clear that e-cigarettes are not risk free but are a fraction of the risk of smoking tobacco. True, PHE is more positive about the role of e-cigarettes for smoking cessation than are the US National Academies of Sciences, Engineering, and Medicine (NASEM), which saw the evidence as unclear, but England is by no means alone in this view, and evidence available after the NASEM review closed provides further support.
The other major point of difference might be on attitudes toward use of e-cigarettes by young people, but those differences are not unreasonable given the different patterns of youth vaping in the United Kingdom and the United States and recent evidence of differential uptake of new products. Rates of regular e-cigarette use in young people remain low in the United Kingdom, and smoking rates among young people continue to decline. The editorial states that in the United Kingdom, there is “evidence already of an increase in adolescent e-cigarette use,” whereas, in fact, rates of ever vaping in youths have not increased in the United Kingdom in the last three years. The editorial has an important misquote of evidence to an Australian parliamentary inquiry.
The published Hansard record is “We say what really matters is the evidence underlying this figure from the Nutt report.” In other words, we are not so interested in the Nutt report but in the underlying evidence on the likely relative hazard. The text given, however, is “the evidence underlying this figure came from the Nutt report,” which implies the opposite. Misleading claims about PHE’s reliance on the methodology of the Nutt report and the claim that they are 95% safer than conventional cigarettes persist despite this having been addressed many times, including almost four years ago by the lead academic authors of the PHE commissioned report.
Veiled references to the role of the tobacco industry repeated again in this editorial are especially egregious and have already been squarely rebutted by the relevant authors.
It may strike readers that the concept of “sunk cost fallacy” could apply to both sides of this debate. Some commentators have an overriding concern about future risks for which no hard evidence yet exists, whereas others are persuaded to act by the extant and emerging evidence of contemporary benefit. Maybe the sky is falling (or will fall in the future), or maybe it won’t. In the meantime, we have an epidemic of tobacco-related harm to address as best we can with the tools currently available.