Updated 13 December 2013. The British Medical Association has written to a number of football clubs urging them to end sponsorship deals with e-cigarette companies and to ban the use of e-cigarettes at their football grounds. I think the lines taken by the BMA are scientifically flawed and likely to cause harm by making it harder for people to quit smoking by switching to vaping. They stress minute obscure risks and ignore huge potential benefits, and they argue with an authority not backed by the quality of science argument. So here is an anonymised example of the letters they have been sending, along with how I would reply if I was an organisation on the receiving end of this.
My suggested reply from any club or other organisation that receives a letter like this… note: no club has sent this to them, but I’d be very happy if they did.
Dear Dr Thomson
Thank you for your letter of 17 October 2013, and for your concern for the health of our supporters. We note the views of the BMA Board of Science with interest, but we have reviewed your position statement on e-cigarettes and did not find the limited account of the scientific understanding of e-cigarettes in the briefing to be sufficient to justify the hostile stance set out in your letter, especially given the views expressed are contentious and disputed by other experts. We can recommend the recent review by Polosa et al 2013: A fresh look at tobacco harm reduction: the case for the electronic cigarette for a more complete account. We would also like to point to a much more enlightened position taken by a group of 10 senior physicians in France (La Parisienne / English extract) and the much more humane and proportionate stance taken by Professor Lynn Kozlowski, Dean of the School of Public Health at Buffalo, State University of New York: 9 things to think about when you think about e-cigarettes. It is a shame that the BMA does not offer this sort of confident leadership in public health.
Our view differs fundamentally from the BMA. We believe that in promoting a very low risk but pleasurable alternative to smoking that also replicates important behavioural rituals, we are encouraging smokers amongst our supporters to switch to these products and thereby to greatly reduce their personal risks. If they then wish to go on and quit using nicotine completely, that is up to them, but in making the initial switch they will avoid nearly all the risks of smoking. We are proud therefore to link our club’s name with e-cigarettes precisely because we are raising awareness of an alternative to smoking. We are much more inclined to the optimism of Professor John Britton, Chair of the Royal College of Physicians Tobacco Advisory Group, speaking to the BBC in June 2013:
“If all the smokers in Britain stopped smoking cigarettes and started smoking e-cigarettes we would save 5 million deaths in people who are alive today. It’s a massive potential public health prize.”
We will pick up some of the specific points raised in your letter below.
A smoking product? Your assertion that we are ‘advertising a smoking product‘ is perplexing. We assume you recognise that in both common sense and in law, “smoking” involves a combustion process. No combustion is involved in e-cigarettes and there are therefore none of the thousands of products of combustion that cause the harms associated with smoking. We regard this difference as the most important feature of e-cigarettes and not something that should be easily confused or misrepresented. The same issue goes to the heart of the BMA’s apparent confusion over the legal status of vaping. The BMA believe e-cigarettes should be included in the smoking ban, but this would be unlawful precisely because there is no combustion. In Scotland, the Smoking, Health and Social Care Act (Scotland) Act 2005, and in England the Health Act 2006, implement the respective governments’ smoke-free policies. These quite properly refer to smoking and smoke as arising from tobacco or other substances that are ‘lit’. This is not accidental or poor drafting: it is combustion that poses the material risk and the reason for controls under this legislation.
Including e-cigarettes in the smoking ban? You say that the the BMA believes that e-cigarettes should be included in the ban on smoking, and would presumably wish to amend the law to allow for this, but you do not really say why. Our understanding is that there is no material risk to bystanders and that any nuisance or irritation arising from other people’s ‘vaping’ is negligible. On the basis that no-one else is harmed or troubled, we see no reason to ban these products. Furthermore, we think there is an opportunity at the stadium to encourage fans to try an alternative to smoking that could be transformational for their health. We do not accept that it poses a risk merely because in some circumstances it can look like smoking, any more than we accept that drinking water in public increases vodka consumption. We credit our supporters, and people generally, with a more considered approach to their lifestyle and their habits. If anything, we expect publicly visible vaping to ‘normalise’ vaping, not smoking, and to encourage switching from cigarettes to e-cigarettes with great benefits. If you have evidence there is a material risk, we would be grateful to receive it. We know of none.
Leading children to smoke? The argument that it might cause children to smoke is highly speculative and implausible. Why would children see vaping and decide to smoke? Why would anyone move from clean, low risk, cheaper nicotine products to the more harmful and anti-social smoking option? There is no evidence suggesting that use amongst non-smokers or children is significant (London-based ASH describes it as ‘extremely rare‘ in children in its May 2013 Factsheet). Nor is there anything to suggest it could could create a gateway for people who would otherwise have never smoked to start smoking. Even if there were emerging use of e-cigarettes among teenagers, it is quite possible that it would be as an alternative to smoking, and therefore highly beneficial – an exit or diversion from smoking (see: we need to talk about the children) and a recent US study suggests ‘gateway theories’ may owe more to ideology and expedient campaigning than good science. As Professor Robert West, one of the UK’s foremost experts in smoking cessation, put it to the BBC in July 2013:
“If those young people are people who would have smoked but instead they’re using e-cigarettes, then that’s a huge public health gain. If they’re people who would never have smoked but they’ve taken up e-cigarettes, frankly in public health terms it’s not really an issue – it’s like drinking coffee or something, there’s no real risk associated with it.
Lack of studies? You move on to argue that there is a “lack of rigorous, peer reviewed studies to support the use of e-cigarettes as a safe and effective nicotine replacement therapy“. It is a pity you have not summarised the studies that have been done in this area and how you interpret them. The research base is developing well and several studies show reasonable smoking cessation efficacy compared to NRT (for example, Bullen et al 2013; Caponnetto et al 2013). However, this is to miss the point. These products are not designed as alternatives to NRT. Their purpose is to provide satisfactory alternatives to smoking cigarettes at a tiny fraction of the risk. The studies that have been done so far understate their potential benefits in at least three ways: (1) more smokers may find this option more appealing and easier than NRT and therefore be willing to try it; (2) users progress over time and learn how to use the products more effectively and may experiment with different products and liquids until they find one that works well for them; (3) the products are evolving and most studies published so far use earlier models now considered obsolete. A good scientific approach would consider all sources of evidence and weight them in an overall assessment – including RCTs, cross-sectional studies, surveillance and surveys, sales data for e-cigarettes and cigarettes, user testimonies and so on. Taken as a whole, the data suggest that e-cigarettes are displacing smoking and reducing cigarette consumption and creating a benefit to health at individual and population level. If you know of other data, please share it and we will consider it alongside your proposals.
Limited regulation? E-cigarettes are covered by extensive safety, consumer protection and commercial regulation – at least 17 European Union Directives apply, including for product safety, electrical safety, packaging and labelling, weights and measures, and fair commercial practices. E-cigarettes obviously are not licensed as medicines because they obviously are not medicines – see the briefing: Are e-cigarettes medicines?). The users are not in treatment, the vendors are not health care providers and we do not regard a football stadium as a clinic. We hope that doctors at the BMA have mustered the professional humility to consult lawyers on the legal status of e-cigarettes. Five courts in the European Union have now found it to be unlawful to designate these products as a medicines. The Legal Affairs Committee of the European Parliament found the same. Legal opinions for two e-cigarette trade associations, ECITA and TVECA, also suggest that it would be unlawful to designate these products as medicines. We do not believe that regulating e-cigarettes as medicines would be beneficial for this important sector even if it was legally possible. We tend to agree with the investment house, BNP Paribas, that what the BMA proposes would aid the tobacco industry:Regulation can change everything: Medical regulation of e-cigs could fundamentally change the category. We believe many current suppliers would struggle to meet medical standards, and for the UK they may have to by 2016. Big players with deeper pockets would survive and prices could rise – a hugely preferable outcome for Tobacco.
Nicotine variability? You refer to varying nicotine content of e-cigarette emissions. If this was a serious problem for users they would not be buying the products in rapidly rising numbers. To the extent that it is an area for product improvement we are confident that innovation in the products will provide the level of consistency that the consumers are seeking at the price they are willing to pay, and that this will improve over time. It is certainly not a reason to over regulate or prohibit the products now. We believe the key to better products is to continue with the rapid pace of innovation seen in the industry over the last couple of years. Your proposals for excessive and unjustified regulation would protect the cigarette category from effective competition, and put a brake on innovation. As the investment bank Wells Fargo puts it:
if e-cig innovation is stifled, in our view this could dramatically slow down conversion from combustible cigs, which would ultimately result in net negative public health impact
Passive vaping? We were surprised that you raised the concept of ‘passive vaping’ in your letter. On what basis does the BMA believe this poses any sort of health risk? Nothing in your briefing or letter justifies this positioning. There are barely any hazardous substances in the vapour itself. They are not merely ‘lower than with smoked cigarettes‘ they are much lower – in some cases hundreds of times lower or undetectable and at residual levels found in pharmaceutical grade products. The exhaled vapour is then greatly diluted in ambient air to the point where we simply cannot foresee any risk. If the BMA believes there are quantitative grounds for concerns about passive vaping, for example with reference to occupational health limits for hazardous substances or some other meaningful proxy for risk, then we would welcome sight of any evidence. In the meantime we regard this idea as a distraction.
A fair assessment of the potential benefits? In proposing that we should end sponsorship and ban e-cigarette use on our premises, the BMA has exclusively emphasised risks and problems, and largely without a credible supporting case. However, the BMA has paid no attention at all to the potential benefits and opportunities that arise from e-cigarettes. If we were to follow your advice and ban e-cigarettes there is risk of a lost opportunity to convert supporters from smoking to vaping, with lost benefits to their health. If the BMA Board of Science wishes to write a convincing letter on this subject, then it needs to weigh the small and implausible risks highlighted in your letter against the potential lost opportunities for health improvement if we were to follow the prohibitionist course you suggest.
We are open-minded and willing to engage in debate based on a reasoned assessment of evidence and even-handed approach to uncertainties. However on the basis of your letter, we will not be reconsidering our sponsorship arrangements with e-cigarettes. We continue to regard the sponsorship as beneficial to health in that it will encourage smokers among our supporters to consider a much safer alternative and to feel that the club is backing them in their efforts to give up cigarettes. We will continue to allow the use of e-cigarettes in the stadium as we believe that seeing e-cigarettes in use will further encourage more of our fans to think about switching. We have seen little to suggest any of the concerns raised in your letter amount to a material risk to the health or welfare of anyone, and we note with disappointment you have dwelt only on speculative downsides but have ignored the very significant potential benefits recognised by other authorities in public heath.
[for the club]
UPDATE 13 November 2013 - on 3 November I e-mailed the BMA (Helen Reilly in Scotland and Vivienne Nathanson in London) to ask for a meeting. No reply so far. So much for open-minded and relentless quest for the best public health policies. Here’s the letter.
Helen ReillyPublic Affairs OfficerBMA ScotlandDear Dr ReillyI am writing in response to the BMA’s campaign to exclude e-cigarettes from football grounds and to its hostile stance on ‘vaping’ more generally.I have written a response to a letter recently sent by the BMA to a football club. I think the BMA’s letter is very one-sided and promotes a number of misunderstandings, and I fear the approach is likely to cause more harm than good. You can see the response I made here:I would very much welcome the opportunity to discuss these concerns with the BMA public affairs function, and to have the opportunity to raise these points with Dr Thomson, Professor Hollins or any other appropriate member of the BMA Board of Science.I would be happy to meet in London, where I am based, or to travel to Scotland as appropriate.My concern is exclusively for public health through ‘harm reduction’ strategies. I have no competing interests and receive no funds from e-cigarette, tobacco or pharmaceutical companies or their agents. I was previously Director of Action on Smoking and Health (1997-2003), hence my interest.Yours sincerely
From: Helen Reilly
Date: 27 November 2013 14:29
Subject: Re: BMA approach to e-cigarettes and vaping
To: Clive Bates
Dear Clive, Unfortunately, I am not able to arrange a meeting, but if you would like to contact members of the Board of Science, you can do so by writing to them c/o BMA House, Tavistock Square, London WC1H 9JP.
Public Affairs Officer
To which I replied…
From: Clive Bates
Date: 29 November 2013 13:55
Subject: Re: BMA approach to e-cigarettes and vaping
To: Helen Reilly
I am surprised. Why are you unable to arrange a meeting? Your organisation is taking an aggressive approach to low risk alternatives to smoking and the people who are benefitting from it. To regard this as violating the medical ethos of ‘first do no harm’ is a credible perspective.
Do you not think it would be better to meet your critics and discuss their concerns? If you are unable to arrange a meeting, I would be happy to. I could probably arrange for you to meet some ‘vapers’ too, if that would be of interest.
Two weeks later (13 Dec) – no response to this offer to facilitate a meeting.