Tobacco: novel products challenging old ethical stances
Smoking is a global killer epidemic. During the 20th century tobacco caused 100 million death – roughly the same number as people killed in both World Wars. Without action, this century it could claim the lives of a billion people, mostly in low and middle income countries. Yet tackling smoking is a tricky business. Regulation must balance several fundamental principles: protecting people from harm whilst preserving human dignity and freedoms.
It is remarkable to observe how attitudes and policy have changed. A little more than 20 years ago, my colleagues would light up in front of me while I was heavily pregnant. It made me feel sick and I knew that the smoke was harmful, but I couldn’t ask them to stop. Their right to smoke took priority.
Back then I helped to organise a workplace ballot to prohibit smoking on the premises. We won by an overwhelming majority; the non-smokers, who had felt unable to speak up individually, made their wishes clear.
My campaigning continued in 2003 when I was recruited by ASH (UK). This evidence-based advocacy organisation was set up by the Royal College of Physicians to reduce the harm caused by tobacco. We were major advocates for the UK’s proposed legislation to ban smoking in indoor public spaces.
Preventing harm, promoting health
The UK consultation and media debates hinged around the question and evidence of harm. The pro-legislation argument won in the end. This was largely because the public accepted that the rights of workers in the hospitality industry to be protected from second-hand smoke superseded the rights of smokers to light up wherever they wanted. Between May 2004 and December 2005, support for smoke-free legislation rose from one half to two thirds of the adult population. It become vote-winning policy and introduced in law in 2007.
ASH is not anti-smoker, but anti-smoking. The distinction is important. I believe there should be balance of rights and responsibilities, for smokers and non-smokers alike and across the globe.
The advent of electronic cigarettes, or e-cigarettes, has once more raised important ethical issues–and this time I worry that perhaps smokers’ rights are being ignored. From Canada to South Africa to New Zealand, with murmurs in France and Germany, countries are banning e-cigarettes or regulating them as strictly as tobacco products.
Yet the science suggests e-cigarettes are much less harmful. Yes, there are rational arguments about potential harm. But the bulk of evidence so far points to public health benefits, certainly in the UK where we engage with smokers and “vapers” to monitor health effects. Perhaps it is really fear of the unknown and a residual desire to punish smokers and vapers that are driving the call for strict regulation?
Research by ASH and government statistics show that almost no-one who is not a smoker is using e-cigarettes. Smokers, meanwhile, are increasingly using e-cigarettes to help them quit; they are proving significantly more effective than medicinal nicotine products bought over the counter. There is little sign that young people other than existing smokersare using e-cigarettes.
It is too soon to say how safe e-cigarette use is longer-term and more research is needed. The precise extent of harm from long-term use is not known, but tests show that the concentrations of potentially harmful inhalants in vapour are likely to be many magnitudes safer than smoking cigarettes. Exhaled vapour is unlikely to cause significant harm to bystanders.
In Europe, we have an evolving twin track regulatory approach which will be in force by 2016/17. It will require novel nicotine delivery devices to be regulated under the EU Tobacco Products Directive or to have a medicines licence.
Ironically, the first licensed e-cigarette will be marketed by a wholly owned subsidiary of British American Tobacco. Despite the vociferous criticism, ASH believes that products, whoever they are made by, should be prescribed on the basis of clinical need. At the same time, we insist that, in line with the WHO Framework Convention on Tobacco Control, this product must not allow any tobacco company a foot in the door to unduly influence tobacco policy.
I understand why so many people want to clamp down with stringent regulation. It is more than 50 years since Richard Doll published the first evidence that smoking caused lung cancer. Yet smoking is still a world-wide epidemic.
We also know that traditional tobacco control policies are effective. But applying the same principles to e-cigarettes may prove to be counter-productive. The evidence that e-cigarettes have great potential for helping adults to quit is compelling, so we should avoid laws that hinder smokers from switching to less harmful alternatives.
I am convinced that banning or heavily regulating e-cigarettes in the same way as tobacco products–even just discouraging their use–does not equate to “do no harm”.
Deborah is Chief Executive of Action on Smoking & Health (ASH UK) and a respected public health campaigner for greater awareness about the tobacco epidemic worldwide. She champions evidence-based policy measures that do not attack smokers or condemn smoking. Reporting to the Royal College of Physicians, ASH provides the secretariat for the UK’s All Party Parliamentary Group on Smoking and Health.
This article is the edited version of a piece that was first published in Science in the Public interest vol. 3: Addictions: Ethics,Integrity and the Policy-Maker, published by SciCom– Making Sense of Science.
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