Policy
Reducing the harm from smoking Opinion among public health professionals was divided on harm reduction in drug use in the 1980s and later on sexual health in the 1990s. It is proving no less controversial for tobacco control in the 21st century. Every year in the United Kingdom, smoking causes around 100,000 deaths, making it the largest cause of preventable death in the UK and killing more people than the next five largest causes combined. Smoking rates are falling, but not fast enough. At about the same time as UK smoke-free laws came into force, a recreational nicotine-containing product (NCP) appeared on the market. E-cigarettes were designed to look like cigarettes but deliver refined nicotine in a suspension of propylene glycol. These products caught the interest of smokers only gradually and by 2010 fewer than 10% of smokers had ever tried them. In the 2008 Action on Smoking and Health (ASH) report Beyond Smoking Kills, Royal Society for Public Health (RSPH) joined with over 100 other health organisations to call for a new plan for tobacco control. The report included a call, not only to provide smokers with alternatives to smoking in the form of commercially available pure nicotine products, but also for a regulatory system that would ensure that these products are safe and effective. Separating the nicotine from the tobacco and smoke made some colleagues optimistic about the prospects of substituting smoking, while the cigarette-like appearance of many NCPs made others wary about the risk of making smoking look normal to children again. In 2013, the National Institute for Health and 5 Questions to ask about an e-cig ban Clinical Excellence (NICE) produced public health guidance on tobacco 1. What are the issues you trying to deal with? harm reduction linked to proposals requiring NCPs to be licensed as 2. What do you think you need to control? medicines by the Medicines and Healthcare Products Regulatory Agency (MHRA). ‘Light touch’ medicines regulation was proposed to 3. Do you have concerns about the possibility of harm from NCPs? ensure that products delivered nicotine safely without being marketed to non-smokers, especially children. 4. Will restricting or prohibiting use of NCPs support smoke-free compliance? The ASH strategy has been to maintain a public health consensus in support of medicines regulation, but this has not been without its 5. Do you want your policy to help to improve people’s health? critics. Some harm-reduction enthusiasts claim that medicine regulation will keep smokers smoking while some harm-reduction sceptics argue that the risk of creating role models for what looks to children like smoking outweighs any possible quits among adult smokers. Nowhere are the differences more deeply held than on public use of electronic cigarettes. Proponents of ‘renormalisation’ argue that the last place you should be allowed to take nicotine is a hospital while supporters of harm reduction respond that banning the use of licensed medicines from hospital grounds would be perverse. They counter the ‘renormalisation’ hypothesis with an alternative view that it is not smoking but the replacement of smoking that will be normalised: children are able to tell the difference in most cases, and every time a smoker uses an e-cigarette, that smoker is publicly asserting the harm their smoking causes. On an issue where we have, so far, often had to rely more on instinct than on research, RSPH supports an emphasis on evidence-based policy making and have joined ASH, the Chartered Institute of Environmental Health and the Trading Standards Institute in a joint briefing ‘Will you permit or prohibit e-cigarette use on your premises – 5 Questions to ask before you decide’. The brief does not come down on either side. While there will certainly be premises where prohibition of some NCPs will be appropriate, there is also an argument that in others – where, for example, smokers trying to quit are obliged to use NCPs only in smoking areas during smoking breaks – a ban may do more harm to health than good. Until the evidence is available to support a more definitive stance on NCPs, you may find the five questions above will help you to wrestle with the issue in your own workplace. Martin Dockrell RSPH Fellow Director of Policy and Research at Action on Smoking and Health
References 1. Briefing on Electronic Cigarettes. June 2013. Available online at: http://ash.org.uk/files/documents/ASH_715.pdf (Last accessed 13th November 2013). 2. Use of e-Cigarettes in Great Britain amongst Adults and Young People. May 2013. Available online at: http://www.ash.org.uk/files/documents/ASH_891.pdf (Last accessed 13th November 2013). 3. Beyond Smoking Kills: Protecting Children, Reducing Inequalities. October 2008. Available online at: http://www.ash.org.uk/beyondsmokingkills (Last accessed 13th November 2013).
6 Perspectives in Public Health l January 2014 Vol 134 No 1
Reducing the harm from smoking Opinion among public health professionals was divided on harm reduction in drug use in the 1980s and later on sexual health in the 1990s. It is proving no less controversial for tobacco control in the 21st century. Every year in the United Kingdom, smoking causes around 100,000 deaths, making it the largest cause of preventable death in the UK and killing more people than the next five largest causes combined. Smoking rates are falling, but not fast enough. At about the same time as UK smoke-free laws came into force, a recreational nicotine-containing product (NCP) appeared on the market. E-cigarettes were designed to look like cigarettes but deliver refined nicotine in a suspension of propylene glycol. These products caught the interest of smokers only gradually and by 2010 fewer than 10% of smokers had ever tried them. In the 2008 Action on Smoking and Health (ASH) report Beyond Smoking Kills, Royal Society for Public Health (RSPH) joined with over 100 other health organisations to call for a new plan for tobacco control. The report included a call, not only to provide smokers with alternatives to smoking in the form of commercially available pure nicotine products, but also for a regulatory system that would ensure that these products are safe and effective. Separating the nicotine from the tobacco and smoke made some colleagues optimistic about the prospects of substituting smoking, while the cigarette-like appearance of many NCPs made others wary about the risk of making smoking look normal to children again. In 2013, the National Institute for Health and 5 Questions to ask about an e-cig ban Clinical Excellence (NICE) produced public health guidance on tobacco 1. What are the issues you trying to deal with? harm reduction linked to proposals requiring NCPs to be licensed as 2. What do you think you need to control? medicines by the Medicines and Healthcare Products Regulatory Agency (MHRA). ‘Light touch’ medicines regulation was proposed to 3. Do you have concerns about the possibility of harm from NCPs? ensure that products delivered nicotine safely without being marketed to non-smokers, especially children. 4. Will restricting or prohibiting use of NCPs support smoke-free compliance? The ASH strategy has been to maintain a public health consensus in support of medicines regulation, but this has not been without its 5. Do you want your policy to help to improve people’s health? critics. Some harm-reduction enthusiasts claim that medicine regulation will keep smokers smoking while some harm-reduction sceptics argue that the risk of creating role models for what looks to children like smoking outweighs any possible quits among adult smokers. Nowhere are the differences more deeply held than on public use of electronic cigarettes. Proponents of ‘renormalisation’ argue that the last place you should be allowed to take nicotine is a hospital while supporters of harm reduction respond that banning the use of licensed medicines from hospital grounds would be perverse. They counter the ‘renormalisation’ hypothesis with an alternative view that it is not smoking but the replacement of smoking that will be normalised: children are able to tell the difference in most cases, and every time a smoker uses an e-cigarette, that smoker is publicly asserting the harm their smoking causes. On an issue where we have, so far, often had to rely more on instinct than on research, RSPH supports an emphasis on evidence-based policy making and have joined ASH, the Chartered Institute of Environmental Health and the Trading Standards Institute in a joint briefing ‘Will you permit or prohibit e-cigarette use on your premises – 5 Questions to ask before you decide’. The brief does not come down on either side. While there will certainly be premises where prohibition of some NCPs will be appropriate, there is also an argument that in others – where, for example, smokers trying to quit are obliged to use NCPs only in smoking areas during smoking breaks – a ban may do more harm to health than good. Until the evidence is available to support a more definitive stance on NCPs, you may find the five questions above will help you to wrestle with the issue in your own workplace. Martin Dockrell RSPH Fellow Director of Policy and Research at Action on Smoking and Health
References 1. Briefing on Electronic Cigarettes. June 2013. Available online at: http://ash.org.uk/files/documents/ASH_715.pdf (Last accessed 13th November 2013). 2. Use of e-Cigarettes in Great Britain amongst Adults and Young People. May 2013. Available online at: http://www.ash.org.uk/files/documents/ASH_891.pdf (Last accessed 13th November 2013). 3. Beyond Smoking Kills: Protecting Children, Reducing Inequalities. October 2008. Available online at: http://www.ash.org.uk/beyondsmokingkills (Last accessed 13th November 2013).
6 Perspectives in Public Health l January 2014 Vol 134 No 1
