Let’s find a balance in the e-cigarette debate

Dr Julie Bishop explains why Public Health Wales is calling for regulation of e-cigarettes

Imagine for a moment that a new product has come to the market and has achieved very rapid uptake with an estimated two million users in the UK alone.  The product is available in a number of forms, some of which are brightly coloured and flavoured in a way that could easily appeal to children.  The substance they contain is highly addictive, there is evidence that some people can become addicted and develop dependency very quickly. There are some negative health effects to its use, particularly on the cardiovascular system. The contents of the product are poisonous when consumed in quantity – there is rising evidence of consultations with the national poisons service on overdoses – particularly among small children.  There are safety concerns that are arising on the quality of manufacture of some of the products with reports of injuries or fires arising from their use.  There are no restrictions on the use of this product so it is becoming widely used in public places, including where children and young people are present.  It is also being heavily advertised, including on television.  It is being sold in a wide range of outlets, crossing traditional product boundaries.

This week on Click on Wales


This week on Click on Wales we have been debating electronic cigarettes in Wales.


Wednesday: Minister for Health and Social Services, Mark Drakeford outlines the Welsh Government’s proposals for regulating e-cigarettes.


Yesterday: Ash Cymru defend a harm reduction perspective of smoking electronic cigarettes.


Today: Dr Julie Bishop explains why Public Health Wales is calling for regulation of e-cigarettes


Tomorrow: Jamie Inshole, a long term smoker, describes the effect that vaping has had on his habit.

Setting aside what we know about the potential benefits to smokers – in any other circumstances is this a product that would be legally available at all, let alone without any restrictions on its sale or promotion?   The answer is clearly no; there would be widespread calls to ban it from sale.  The only reason that we are even considering its availability is because it is less harmful than a currently available lethal product.

Unfortunately, at the moment the public health/tobacco control community seems to be split.  One group expressing concerns about the product itself, others only seeing the potential benefits to current smokers.  Public Health Wales’ view is that it is possible to find a balance, a compromise position that addresses the needs and concerns of both sides.

The ‘precautionary principle’ is well established in public health.  Where we have some evidence, for example from theory or basic science or from other fields of health, that something may have negative health effects, we act on that basis not waiting for conclusive evidence of harm.  It is true that we don’t have conclusive evidence that children will take up e-cigs and start vaping in large numbers but there is sufficient evidence to suggest it is a risk.  Why wouldn’t they, they are seeing it all around them, it is being widely advertised, adults do it and perhaps of greatest concern – it is widely touted as being safe.

We believe that if e-cigs are regulated and treated as a tobacco product (providing they do not make claims about helping people quit) they should be legally available.  This means that they would be subject to the same sales and marketing restrictions as cigarettes and the same rules on where they can be used.  This, we believe, would help reduce the potential risks and harms of e-cigs, particularly to the young.  For smokers, they would be able to make the safer choice if that is their preference – we would advocate it should be a last resort, quitting is still the best option.  They would still be gaining compared to continuing to use tobacco; they can take steps to reduce their risk.  They cannot currently smoke tobacco where and when they choose so it seems illogical to argue that they are somehow disadvantaged by not being allowed to vape where and when they like.

There is a win/win situation possible here. It is important that the public health community does not allow the considerable vested interests in this debate to introduce tensions and divisions which ultimately can only harm public health.

Dr Julie Bishop is a consultant in public health for Public Health Wales

16 thoughts on “Let’s find a balance in the e-cigarette debate

  1. You do know that first paragraph also described coffee perfectly, don’t you? Seriously, MS. Bishop, climb down off your high horse and, ahem, smell the coffee – you should be supporting and promoting ecigs, not clutching at straws to get their use banned.

  2. If you are going to cite the ‘precautionary principle’ as an argument to place regulations on e-cigarettes, as Clive Bates has stated elsewhere, you also need to include the potential benefits in the decision. All too often, people in Public Health only want to include the negative aspects to justify regulatory action without looking at the positives or, indeed, the unintended consequences of taking or not taking action.

    The overriding benefit in the case of these devices is that they are an order of magnitude safer than smoking and that is recognised by leading experts in the field (well, at least 53 who have signed the recent letter to the WHO). Why would any public health professional stand in the way of this bottom-up revolution in harm reduction, that has not cost the taxpayer a penny and will save or extend life by the millions worldwide?

    Yes, by all means tighten up the controls on e-liquid content and packaging and restrict sales to minors. Also put monitoring systems in place to provide early warning of any of the concerns that have been identified (but not yet materialised). This is sensible regulation at the early stage of the product’s life cycle. But why on earth is there any justification to go further at this stage of knowledge? As Professor Hayek said, if penicillin had been treated the way e-cigarettes are by Public Health, it would never have been introduced and 1000’s of lives would have been lost as a result.

    The precautionary principle is a double-edged sword and by not adopting a rational approach and following it’s precepts correctly, the Public Health community may well end up harming the health of the public instead of doing the job that we all pay for.

  3. Dr Bishop is at best disingenuous in her thinking. The only gateway evidence is clearly away from tobacco, and there is no evidence that there is a risk of children taking up vaping in large numbers. The e-cig trade body ECITA members and virtually all outlets already have a voluntary policy of not selling to under-18s and have had for some years, without any legislative boot up their backsides.

    ” in any other circumstances is this a product that would be legally available at all, let alone without any restrictions on its sale or promotion? The answer is clearly no; there would be widespread calls to ban it from sale. The only reason that we are even considering its availability is because it is less harmful than a currently available lethal product.” …….and what is the basis for this paragraph? As I can’t rationalise it at all, some insight would be useful.

    Flavourings are good, they help the ex-smoker remain such, especially when your tastebuds come back to life when the remnants of smoke have had chance to clear out…do I vape fruit/sweet/other non-tobacco flavours? You bet I do, despite being a 40-odd year old grown-up. Myself and vapers everywhere wish people in positions such as Dr Bishop could get their heads around this issue, the “aimed at children” thing is just plain wrong !!

    Oh, and Personal Vapourisers are already regulated, not as tobacco products or medicines, which they obviously aren’t, but by around 18 consumer product regulations, which they clearly are.

  4. Ms. Bishop cites the precautionary principle, and then goes on to misapply it. She would perhaps like to converse with Prof Antoine Flahault, who coined the Precautionary Principle for the WHO. He will tell her that, in this case, her interpretation of it is completely wrong, and that she will, should she get her own way, do much more harm than good. She should heed Prof Hajek and his Pennicillin example, rather than cling to Prof McKee and his shameful outbursts.

  5. You lost me at “Setting aside what we know about the potential benefits to smokers…” How could you possibly set that aside? How is it going to help the children to see people who are choosing a vastly safer alternative shunned and stigmatised in the same way that smokers are?

    There is no evidence at all that the vapour exhaled is a risk for bystanders so there is no health justification for banning them in enclosed public places. In the absence of that excuse you rely on the precautionary principle in asserting that seeing people vaping might at some time in the future (even though there is no evidence for it so far) encourage youth to initiate use. No doubt some will anyway, whether you ban indoor use or not. Perhaps some will BECAUSE you banned indoor use so giving out the message that e-cigarettes are bad, and therefore a tool of rebellion. But it’s likely that those young people will be the same people who would have taken up smoking (that is still happening despite the best efforts of tobacco control) and it would be preferable if they experimented with a safer alternative. Age restrictions and regulated advertising would be sufficient to prevent the deliberate targeting of young people.

    And then there is the other side of the precautionary principle coin, which I see you are intent on ignoring. The risk that bringing in bans and restrictions will turn current and potential future vapers away from the safer product and back to tobacco. This is a very real risk and appears to have been born out in Spain and Italy, where usage restrictions and excessive tax have preceeded dramatic drops in sales. So basically what you are doing in applying the precautionary principle in such a one sided way is gambling the lives and health of millions against a perceived future risk, the existence of which you have no evidence for.

    Nicotine itself is a very well understood drug and has a risk profile similar to caffeine when used as intended. I would also remind you that it is legal. Governments should have very good reasons founded in sound evidence before restricting the liberty of people to use it as they choose, or to restrict the right of property owners and employers to decide what they will allow on their premises. You have no such evidence, and are ignoring the risk that applying restrictions will raise.

  6. Imagine there was a product that caused no perceivable harm to anyone and replaced the widespread usage of a product that did actually kill half of its users. Would anyone be so obtuse as to limit the appeal and uptake of it?

    Ecigs aren’t regulated as a tobacco product for the simple reason that they aren’t a tobacco product, tobacco products contain tobacco. Treating vapers as smokers, sending them out into the smoking shelters reduces the appeal and greatly increases the temptation to smoke, and it is powerful, in particular for new vapers, makes as much sense as holding an AA meeting in a bar because they’re alcoholics anyway they shouldn’t complain

  7. Dr Bishop, having smoked for nearly 40 years my interest was peaked back in November 2012 by E-cigs. I tried a cigalike (the ones that look like a cigarette) and to my surprise found that the use was almost acceptable. I then used the internet (which you of course have used to get your mountain of research) and discovered that there were other devices and flavours available. I dual fueled for about six weeks (this means I had both cogarettes and E-cigs) and was down to just the first one in the morning. Then one morning I just didn’t want the cigarette because I wanted my Stawberry and Mint, Who would have believed it! I hadn’t started using these devices because I wanted to “quit”, I was curious as to how they worked and how effective they could be. I now use third generation devices with loads of different flavours (currently coffee and hazlenut as it is the morning) and can never see myself going back unless you and your misguided cohorts ban them only to replace them with ineffective pharm or Big Tobacco products. Our devices (research by ASH) have 700,000 fully switched users in 5 years at nil cost to the NHS or tax payer. NRT have got no where near that number in 10 years and at great expense.

    As Peter Hayek said, “if we had treated penecillin the same as we are trying (and I really hope you do fail for the health of everyone) to treat E-cigs 1000’s of people would be dead that could have led full lives”.

    Please, please, please rethink your position.

  8. I wish you would do some research comments like this show a lack of knowledge….
    ‘There are some negative health effects to its use, particularly on the cardiovascular system’
    ‘The substance they contain is highly addictive’

    You should have a look at these for starters…

    no adverse effects on blood and oxygen supply to the heart
    Electronic cigarettes, contrary to tobacco, do not stiffen the arteries
    nicotine by itself isn’t very addictive

    Public health & tobacco control is not as divided as you believe there has been a very rapid change of position in the last couple of months which is gaining momentum. Public health Wales has a choice it can go with the evidence based harm reduction approach that England is taking or continue with its present evidence less dangerous ideas.

    Finally as someone who smoked for 40 years & stopped instantly by switching to ecigs can you explain why you want me as a non smoker to have to stand outside with the smokers.

  9. Leaving aside the ideological, vested interest of public health officials, let’s look at what you said Dr Bishop. In the first paragraph you make many unsubstantiated claims about harm, that are so general that they could be applied to an enormous number of legally enjoyed consumer products that are readily available ans loved by millions of people. You seem to imply that by not calling for an outright ban you are somehow being fair to vapers. Where you do cite harm you fail cite sources as if respiratory damage and appeal to children are facets of vaping which are beyond doubt. They are not. Just the first few linearity this piece highlight how unfit you are to hold the position you do. You are either deeply manipulative or wilfully ignorant. Neither are great qualities for someone charged with protecting the health of the public. You appear to be operating that vapers are smokers and that because of years of vindictive marginalization you can say whatever you like and it will be accepted by everyone. I hope that my comment and the many others on here dissavail you of that notion. You are being held to account.

  10. The precautionary principle argument misquoted yet again. If that had been applied as she suggests to mobile phones (remember the cancer causing concerns) then none of us would be allowed to have one.
    Protecting us against imaginary risks is also just a lie. Crossing the road & driving cars causes huge numbers of injuries and deaths every year. Should the “precautionary principle” be applied to these activities or sky diving, cycling, god, the list becomes endless. This is one of the weakest arguments ever, and inevitably comes out when no rational or scientific basis for an argument is available. Every aspect of life is a gamble. We are grown up enough to calculate our own risk tolerance. The nanny state is not wanted and definitely not needed.
    Seriously, get a grip out there!!

  11. People here have mentioned caffeine. The wowsers and the killjoys have been out to get caffeine for decades. There have been innumerable studies into its effects. Some have claimed to find problems, usually not severe, but further work has contradicted them or produced inconclusive evidence. The only conclusion I can draw is that caffeine has no deleterious effects at all unless consumed in implausible or impossible quantities because, if it had, such a determined effort to find them would have produced much more conclusive evidence. In fact I suspect caffeine must be really rather good for you if years and millions devoted to finding the opposite have produced so little. No comparison with nicotine and associated tars which are proven carcinogenics.

  12. Very sad to see a spokesman for PHW calling for regulation that will result in more death and misery rather than less.

    It is obvious that PHW oppose e-cigs from ideological point of view rather than a public health perspective. However even that ideological view point is flawed – e-cigs, if encouraged could destroy the current tobacco market, surely something that PHW would welcome.

    PHW, don’t be part of the problem, be part of the solution. Public Health England appear to have ditched their initial unfounded concerns regarding e-cigs, can you do the same?

  13. In response to this post I’d just like to submit this excellent piece.


    In response to R Tredwyn’s remarks, especially this line ” No comparison with nicotine and associated tars which are proven carcinogenics. ”

    Nicotine is not carcinogenic. TAR as applied to cigarette smoke is an acronym for “Total Aerosol Residue.” Nicotine may be present as a part of that TAR, but that does not prove its harm. While some research shows that tobacco-free nicotine use can produce some negative effects, the majority of recent research suggests that nicotine itself is about as harmful as caffeine; this is not intended to demonise caffeine, but to explain that nicotine is less harmful than is generally argued. Nicotine has not caused addiction or withdrawal when used to treat disease. Caffeine is a natural substance that is toxic in high dose. It has a similar effect to nicotine on the body in use. Caffeine is used medically to improve the uptake of pain killers (amongst other uses) and as a consumer product, with guidelines but no legal limits or restrictions.

    You wouldn’t want a baby or your pet drinking strong energy drinks or chewing caffeine tablets either, would you? What we should not do is become hysterical about the evils of having either caffeine or nicotine around us.

  14. For once, just ONCE, please could someone who loves ecigarettes provide INDEPENDENT research about their use and effect. And by independent, I mean where NONE of the research was funded by the tobacco or ecig industry – that means you have someone independent like a University setting the questions to ask participants, identifying the participants themselves, studying the effects over a LONG TIME, setting the boundaries of the study etc. And none of the money for this comes from the tobacco or ecig industry either directly or indirectly. Maybe then a genuine public health debate could take place!

  15. JC I & others have linked to research that has not been funded by big T or the ecig industry, the tobacco industry to my knowledge does not fund any ecig research they would prefer that ecigs didn’t exist & the ecig industry funds very little research.

    This is gives an idea of what is going on in England…
    http://www.ncsct.co.uk/usr/pub/e-cigarette_briefing.pdf briefing for stop smoking services
    http://www.rcplondon.ac.uk/commentary/what-you-need-know-about-electronic-cigarettes Royal College of Physicians. Just in case you cant be bothered to check those links heres the last paragraph from the Royal College of Physicians link

    Despite the controversies, it is clear that e-cigarettes are far less hazardous than is tobacco. With more than a million UK smokers using them to help to cut down or quit smoking, they are proving to be valuable harm reduction and cessation products and could make a substantial contribution to reducing the burden of death, disability and poverty currently caused by tobacco smoking. Health professionals should embrace this potential by encouraging smokers, particularly those disinclined to use licensed nicotine replacement therapies, to try them, and, when possible, to do so in conjunction with existing NHS smoking cessation and harm reduction support. E-cigarettes will save lives, and we should support their use.

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