Electronic cigarette interviews
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ECD: The WHO amongst others have raised concerns about the delivery of nicotine to the lungs via the device. Is this a concern you share?
ML: First we now know that the nicotine dose per puff is low, and more puffs need to be taken to satisfy cravings as do tobacco cigarettes. Secondly we find that the e-cigarette nicotine is more likely absorbed in the upper airways rather than in the lungs – and so it will not be delivered very rapidly to the brain as in the case of the tobacco cigarette.
The lower nicotine per puff in the e-cigarette and the slower uptake compared with tobacco cigarettes means the addiction risk is probably low. Perhaps e-cigarettes could be made more satisfying, without impairing the taste. Such e-brands may already exist, but the lack of research funds means we just do not know which they are. E-cigarette distributors wishing to move product, and public health agencies, wishing to save lives, need to pay much closer attention to nicotine deliveries, because without sufficient nicotine, e-cigarettes will not satisfy as cigarette substitutes.
ECD: By using an electronic cigarette, using what we know of the ingredients, in what ways could a smoker expect their health to improve?
ML: The main health advantage of using the electronic cigarette is if and when it replaces tobacco cigarettes, which carry a one in two risk of early death. Those who quit smoking tobacco by any other means such as cold turkey also reap that advantage as long as they do not relapse.
E-cigarette users should switch completely or quit nicotine completely and avoid even one tobacco cigarette per day, as even a single cigarette daily greatly increases the risk of a heart attack.
Propylene glycol, the main ingredient of e-cigarette mist, is known to kill airborne flu virus and bacteria, and tends to protect those exposed to it in inhaled air, whereas in contrast smoking tobacco doubles the risk of death in a flu epidemic. However we don't have any data as to the extent that propylene glycol inhaled intermittently from an e-cigarette might prevent inhalation of live bacteria and viruses. This merits research.
ECD: What conditions are not likely to improve after switching to the electronic cigarette?
ML: Electronic cigarettes will not protect from diseases and damage due to past tobacco smoking, but they can help the smoker to stop making things much worse by continued inhalation of irritant and toxic tobacco smoke.
ECD: Despite your own studies in New Zealand and many supporters in the Tobacco Harm Reduction community, electronic cigarettes have been banned in Australia and in your own country, New Zealand; there seems to be a defacto ban in Canada and they look likely to be made illegal in the US under requirements which require testing which is physically impossible to carry out. Yet such a ban on a product so much safer than cigarettes seems absurd. What is the reason for the opposition to the electronic cigarette?
ML: Most regulators would privately agree the system is absurd. E-cigarettes are caught in a two-box regulatory trap. Nicotine products are in law usually either tobacco products or medicines. A choice between only two options is a dilemma for the regulator.
E-cigarettes, seeking to be tobacco-free, no longer fit the first box.
So regulators classify it in the second box, as a medicine.
From a smoker's viewpoint, however, it belongs in a third box, as a lifestyle choice or cigarette alternative. It is also a question of market power. Big Tobacco controls Box no. 1, Big Pharma and the white coat health professional prescribers and dispensers control box no 2, while many smokers addicted to nicotine, the ones most likely to be sitting on death row, are powerless. They would like to buy from Box no. 3, but it is empty.
ECD: One study in Europe has suggested that making Snus illegal has cost thousands of European lives. While obviously difficult to quantify, in your opinion would a ban on the electronic cigarette in the US cost the lives of smokers?
ML: Making snus illegal in Europe has helped ensure that the popularity of snus in Swedish men, the low cigarette smoking rates in men, and the low Swedish lung cancer rates in men have not benefited men in Europe. Compared with snus, the e-cigarette has the advantage of appealing to both women and men. Bans on electronic cigarette in countries such as the United States could frustrate efforts to know whether the e-cigarette can wrest market share from tobacco cigarettes.
If I can, then a ban on their sale would crimp their potential to save lives. However, we need some statistics as to how many e-cigarettes have sold industry-wide, and how many of these customers are still smoking.
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Interviewer: James Dunworth