E-cigarettes a public health breakthrough
On Aug, 4, the local heath unit’s Medical Officer of Health Dr. Lynn Noseworthy wrote a column for this newspaper urging caution on e-cigarettes and supporting restrictions by the Ontario government that would make it harder for smokers to switch.
As someone who has spent over three decades in the forefront of national and global efforts to reduce smoking I feel a need to provide some perspective. As someone who grew up in Port Hope and observed friends starting to smoke and then, unable to break their dependence, succumb to tragically premature deaths, I cannot fail to speak out.
Despite all the success over the years in reducing smoking, cigarettes are still by far the greatest preventable cause of death in Canada. They currently claim roughly 37,000 lives a year. I learned long ago to make such numbers more real by imagining the actual people involved. As Port Hope had roughly 10,000 people at the time I left for university I learned to count deaths in ‘Port-Hope-equivalents’, so in terms of lives lost the annual toll from smoking is like the death of everyone in the town, nearly four times over. And repeated year after year. Just thinking about such a totally unnecessary and ongoing tragedy causes the mind to recoil in horror.
But in our efforts to reduce this horrendous toll too many people have lost sight of a truly important fact. While people smoke for the nicotine, they die from the smoke. Smokers are dependent on the drug, but are dying in such tragic numbers due to a very deadly delivery system. If we got caffeine by smoking rather than brewing tea leaves the result would be the same. The human body is just not built to withstand repeated inhalation of the products of combustion.
So how dangerous are the vapour products that are allowing so many people to get off cigarettes? Well, the Royal College of Physicians in the UK, probably the most prestigious medical body in the world, issued a comprehensive report on the state of the science on these products earlier this year. It is well worth reading for anyone seeking facts rather than simply trying to justify opinions (and should be mandatory reading for local health units) and the key conclusion was:
“Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5 percent of those associated with smoked tobacco products, and may well be substantially lower than this figure”. (Section 5.5 page 87).
Of course there is research that is used in public relations efforts to attack any alternatives to cigarettes. This has been ongoing since long before my career in the field even began. That is no surprise given that the global cigarette trade is roughly a trillion dollars a year. Plus, some people adhere to a total ‘abstinence-only’ view on nicotine, so refuse to accept risk reduction as an acceptable health intervention. But we need to cut through ideological and commercial biases if we are going to most effectively reduce disease rates.
We need to look at the totality of the science, as has the Royal College of Physicians. People who pick information to fit an ideological agenda rather than use facts to inform their opinions are a threat to health when they perpetuate smoking. Dr. Noseworthy fell into that trap. She cites two studies, claiming that formaldehyde and a chemical shown to cause respiratory disease are found in e-cigarette vapour, but missed the fact that both studies have been debunked. Yes, one can create formaldehyde by testing an e-cigarette at a setting so hot that consumers would not willingly inhale it, something no more credible than someone who claims bread is carcinogenic because they tested severely burnt toast. The same goes for those who claim to find a substance (diacetyl) that is a cause of respiratory disease without disclosing that cigarettes have 750 times the level, and that even in cigarettes it does not seem to be high enough to be a significant risk. Such people are ignoring the first rule of toxicology – that ‘the dose makes the poison’.
Any risk has to be seen in relation to the alternative, which in the case of these vapour products, is the extraordinarily lethal cigarette. Looking at a ‘risk’ without determining if it would actually be a threat under normal use of the product and without comparing it to the risk of smoking is more likely to mislead than to inform smokers. Jumping out of an airplane with a parachute is dangerous, but we don’t discourage it when the alternative is jumping without one.
In effective public health efforts we need to be pragmatic. We might not personally like what others are doing but we still strive to reduce their risks. Through efforts of risk reduction, we have dramatically reduced numerous causes of death, injury and disease. Sometimes it is as easy as getting goalies to wear facemasks. Sometimes it is largely technological such as the way we have reduced automobile fatality rates in Canada by over 80% since the time I was a teenager. Often it is controversial, such as messages on safer sexual practices or risk reduction efforts for users of illicit drugs. In the case of smoking, where cigarettes kill roughly half of long term users it should be easy, at least if we can avoid the manufactured controversies that have dogged this field for over half a century. If we get rid of the inhalation of smoke, something smokers already want to do, we can basically solve the problem.
Do we need regulation? Likely even if I were not a lawyer who has spent 33 years actively seeking regulations to reduce smoking, I’d still say ‘of course!’ But we need regulations that facilitate rather than obstruct the vast majority of smokers who want to quit. We have rules now to prevent sales to minors, which is important. But we need regulations that help make these products more widely available to smokers and facilitate them learning the proper use of such devices, that give the far less hazardous alternatives a marketplace advantage over lethal cigarettes, that spur development of ever better products to facilitate smoking cessation, that set reasonable safety standards for all such innovative products and that ensure smokers are given truthful and non-misleading information on relative risks.
Can we truly eliminate the scourge of our leading cause of cancer death through innovative technology? Not only can it be done, but it has been done before. As recently as the 1940s stomach cancer was our leading cause of cancer death. But it fell dramatically to the point that it is now mercifully rare. What happened? In a word, refrigeration. The innovative technology of refrigeration allowed consumers to change their diets in ways they wished to. Far less highly salted, pickled and smoked foods, far less contaminated food, and more fresh fruits and vegetables. Entrepreneurs embracing innovative new technology met a consumer demand, creating jobs and paying taxes in the process, and a cancer epidemic was largely eliminated.
So, yes, let’s work with smokers and the local vape shops as we start a revolution that can rid us of cigarettes and the diseases they cause. But let’s also take a moment to think of those who had the initiative to start providing reliable refrigeration back in the 1940s, and if you happen to know such a guy, go give him a hug. He’s a public health hero.
David T. Sweanor J.D. is Adjunct Professor, Faculty of Law, University of Ottawa, a member of The Centre for Health Law, Policy & Ethics, University of Ottawa, an Honorary (Consultant) Assistant Professor, University of Nottingham, England, was Legal Counsel to the Non-Smokers’ Rights Association, 1983-2005 and has worked with groups such as the World Health Organization and the World Bank, testified before numerous parliamentary and US congressional committees, and been actively involved in lawsuits against cigarette companies. He grew up in Port Hope, helping to fund his way through university in part by delivering refrigerators for Joice-Sweanor, the family business, which was started by his (heroic) father Trevor in 1945.