NICE Issue Guidelines To GPs on E-cigarettes

The National Institute for Health and Clinical Excellence (NICE) arranged for mass media publication on 4th June 2013 of news that NICE has now issued guidelines to GP's that recommend that some people should try to limit their smoking while using nicotine gum and skin patches as a supplement, instead of simply stopping the habit.¹

This now makes Britain the only country in the world to recommend that licensed nicotine-containing products should be prescribed to people who only want to reduce the number of cigarettes they smoke, even if they have no intention of quitting altogether.

Previous advice has simply told smokers to quit the habit altogether and use NRTs instead, but research shows that people who cut down on their smoking while using NRTs such as gum are more likely to quit altogether in future.

Apparently, up until now e-cigarettes have not been officially recommended because there is no monitoring of what they contain or whether any ingredients could be harmful.

Despite this not having changed, the guidance from NICE now advises that controversial electronic cigarettes, which are unregulated, are "likely to be less harmful than cigarettes".

The guidance states that while their "effectiveness, safety and quality can't be assured", doctors should "also advise [patients] that these products are likely to be less harmful than cigarettes."

The new advice issued by NICE means that for the cost of a prescription charge, smokers should be able to receive licensed "nicotine replacement therapies" (NRTs) such as gum and electronic cigarettes from their doctor even if they do not intend to quit completely.

Whereas, without a prescription, a person smoking 20 cigarettes a day would spend an average of £860 a year on such products while trying to quit, NICE said.

Unlike tobacco products, there are very few advertising restrictions, but regulation is under discussion.

Whilst not mentioned in the NICE press release the Advertising Standards Authority has already successfully challenged agressive e-cigarette industry advertising for making claims that suggest that e-cigarettes are 'harmless' - claims that couldn't be substantiated by the advertisers.

The British Medical Association says it is concerned that there is a lack of rigorous, peer-reviewed studies to support the claim that e-cigarettes are a safe and effective form of nicotine-replacement therapy. Until such studies exist, it wants the sale of e-cigarettes regulated, as well as a ban on their use in public places – as is being implemented in France.

"These devices directly undermine the effects and intentions of existing legislation including the ban on smoking in enclosed public spaces," says Richard Jarvis, co-chair of the BMA's public health medicine committee.

On the question of whether e-cigarettes are safe, Vivienne Nathanson, the BMA's director of professional activities, is also clear: "The simple answer is we don't know."

In 2011 it was reported that the government's "nudge unit", in what appears to be a response to industry pressure, wanted to encourage the use of smokeless nicotine cigarettes, banned in many countries around the world, in an attempt to reduce the numbers killed in the UK by smoking diseases each year.²

A Cabinet Office source said: "A lot of countries are moving to ban this stuff; we think that's a mistake."

Apparently experts have advised the UK government that the nicotine contained in some new, smoke-free cigarettes is no more harmful than caffeine in coffee.

[Note. Investigations by TSS Supporters have revealed one possible source of this misleading statement regarding caffeine and nicotine: "Our strategy is based on the fact that nicotine, while addictive, is about as safe as caffeine," testified University of Alabama Professor Brad Rodu before a June 3, 2003 congressional subcommittee. Professor Rodu, whose research was funded by United States Smokeless Tobacco Company, contends that smokeless tobacco is safer than smoking.]³

However independent research indicates that Nicotine is 166 times more deadly than caffeine - the lethal dose for nicotine being generally considered to be just 60 mg of nicotine to kill a 160 pound man, whilst the lethal dose for arsenic is 200 mg, and the lethal dose for caffeine is 10,000mg.

John Polito, a smoking cessation specialist, has previously said "Any assertion that nicotine is as harmless as caffeine must divorce itself from the deadly reality that nicotine is not a bean stimulant but a potent natural insecticide engineered by nature to protect the tobacco plant from being eaten by insects."³

In December 2012 BAT (British American Tobacco), Britain's biggest tobacco company acquired CN Creative, a Manchester-based company which specialises in the development and production of non-combustible e-cigarettes. The takeover is believed to be costing BAT tens of millions of pounds, but insiders say the purchase will be of potentially far-reaching strategic importance to the group.⁴

Notably, in December 2000 Nottingham University accepted £3.8 million in funding from British American Tobacco. The university was internationally condemned and several researchers and professors resigned over the issue. Tobacco industry funding of universities around the world continues to be an issue.⁵

John Britton, professor of epidemiology and Director of the UK Centre for Tobacco Control Studies at the University of Nottingham has said in the past that "on top of the current smokeless range – which includes electronic or "e-cigarettes" that simulate smoking by producing an inhaled mist – there are three or four devices in different stages of development. But he said some companies have been reluctant to develop this technology because they had expected it to be as tightly controlled as pharmaceutical drugs."²

Meanwhile, on June 3rd, the day before the NICE guidelines were announced, and in what appears to be a co-ordinated attempt to push nicotine as a new wonder drug, BAT released a press note in the on-line magazine www.tobaccoreporter.com, detailing the results of a survey commissioned by BAT, and published with the headline "GPs need a course on nicotine".⁶

The survey involved an online survey to assess the knowledge, perceptions and attitudes to tobacco and nicotine products of healthcare professionals in the UK and Sweden and to understand what types of advice in relation to the use for alternative nicotine products are being offered to smokers.

“It is our belief that smokers should have available to them products that are satisfying and deliver nicotine in a safer way without the harmful toxicants in cigarette smoke,” said Dr. David O’Reilly, group scientific director at BAT. “And those responsible for giving advice to smokers on different tobacco and nicotine products must be able to provide accurate and meaningful information on their different risk profiles.”

‘The survey findings show that a substantial proportion of GPs (40 per cent) believe nicotine to be the first or second riskiest component of cigarettes, incorrectly identifying it as more harmful than smoke. Many (44 per cent UK, 56 per cent Sweden) also wrongly believe that nicotine in tobacco products is associated with cancer, while 15 per cent in the UK and 22 per cent in Sweden believe the same for pharmaceutical nicotine.’

“Although GPs clearly understand that smoking is more dangerous than NRT use, it is worrying that so many associate nicotine with cancer,” said lead researcher Dr. Sudhanshu Patwardhan, medical affairs manager at BAT. “It is also unclear whether the perceived risk of nicotine in tobacco and NRT is because of this association with cancer or because of its ability to cause addiction."

However, putting to one side for a moment the concerns of BAT researchers, who appear to not have heard of using the internet and wikipedia as a research tool, it was noted that the revised NICE guidelines, and the BAT press note, were released just one week after reports of the death of an Israeli toddler; having died as a result of ingestion of the nicotine solution used by e-cigarettes.⁷

Nevertheless, in the press release, NICE included no guidelines or warnings about any new hazards that are associated with e-cig technology, for example, the likely effect of children being attracted to any aromatically flavoured, yet poisonous, nicotine liquid that might be 'vaped' with electronic cigarettes.

Further research into the likely impact of the NICE guidelines is currently the subject of an investigation by The Smokeless Society's Behavioural Insights Team...

If you are concerned about the development of electronic cigarettes by the Nicotine Industry, please register on this website as a supporter of the Smokeless Society, sign the government e-Petition, and ask your friends to do the same.

Sources

1. The announcement was given prominence in many publications:

http://www.telegraph.co.uk/health/healthnews/10099325/Smokers-urged-to-cut-down-rather-than-quit.html

http://www.guardian.co.uk/society/2013/jun/04/e-cigarettes-health-revolution-smokers?INTCMP=SRCH&commentpage=4

http://www.cancerresearchuk.org/cancer-info/news/archive/cancernews/2013-06-05-NICE-issues-new-guidance-in-anti-smoking-fight?view=rss

http://www.dailymail.co.uk/health/article-2336027/E-cigs-safer-option-New-guidelines-urge-doctors-advise-products-smokers-finding-difficult-quit.html?ito=feeds-newsxml

http://www.express.co.uk/news/health/405073/New-UK-rules-promoting-harm-reduction-help-smokers-to-give-up

2. UK Government Nudge Unit - Behavioural Insights Team

http://www.guardian.co.uk/commentisfree/2011/sep/19/government-nudge-unit-behavioural-insights-team

http://www.guardian.co.uk/society/2011/sep/14/smokeless-nicotine-cigarettes-government

3. Nicotine vs. Caffeine

http://whyquit.com/pr/021606.html

4. BAT wants to turn electronic cigarettes into 'medicine'

http://news.sky.com/story/1027436/british-american-tobacco-in-e-cigarettes-deal
http://www.esontechnologies.com/blog/2013/bat-claims-electronic-cigarettes-are-healthier/

5. University funding and the tobacco industry

http://news.bbc.co.uk/1/hi/business/1055365.stm
http://www.eurekalert.org/pub_releases/2008-01/uon-ucf012208.php

6. BAT Survey on GPs knowledge of nicotine

http://www.tobaccoreporter.com/2013/06/gps-need-a-course-on-nicotine/

7. 30 month old toddler killed by e-cigarette in Israel

http://www.theyeshivaworld.com/news/General+News/170198/Toddler-Who-Ingested-Nicotine-Drop-From-Electric-Cigarette-was-Niftar-in-Jerusalem-Hospital.html

http://www.jpost.com/Breaking-News/Toddler-who-ingested-liquid-nicotine-passes-away-314683

29 May 2013 Israeli Toddler Killed By E-cigarette

Last updated - 12th June 2013