Israel to ban e-cigarettes…? More self-harming evidence-free unethical public health policy

Oh dear … Israel planning to ban e-cigarettes. I’ve responded to the consultation as below. You’ll need Google translate (the screen shot above is generated by Google) and I ended up sending my response to the site administrator as it was rejected by the web form on the site. Here’s my response. If you know Israeli vapers, please pass this on and extend my offer of solidarity.

Dear sir / madam

I am writing to urge the government of Israel not to ban e-cigarettes. While it would be harmful to public health in Israel, it would also send a terrible signal to the many countries that respect Israel for its science, innovation and modernity. I think the decision is of international significance, and I would like to represent a view to the government of Israel from outside the country.

The potential. E-cigarettes have astonishing potential to reduce the expected toll of tobacco-related death an disease in the 21st Century. The WHO anticipates one billion premature deaths from tobacco on current trends would arise this century. Tobacco use is widespread and growing around the world – there are 1.1 billion smokers in the world today, and if current trends continue, that number is expected to increase to 1.6 billion by the year 2025. Even in Israel where there has been years of determined public health campaigning and regulation, around one in five adults smoke – and the decline that was evident from the 1940s onwards has slowed in the last ten years. We need to embrace the concept of tobacco harm reduction, recognise the reality of continuing widespread nicotine use and design strategies to mitigate the damage. We must not let the unrealistic perfect be the enemy of the achievable good. The danger of that is that we present users with a ‘quit or die’ ultimatum. E-cigarettes offer the potential of a different way of taking nicotine – and huge benefits may flow from that if e-cigarettes capture a significant share of what would otherwise be a market for tobacco cigarettes.

The benefits. We already know much about e-cigarettes, what is in them and how they work – it is not an area untouched by science. E-cigarette sales have been growing at an extremely high rate worldwide from a small base, and there are many eloquent testimonies from “vapers” detailing how important these products are to them. What lies behind this success is that they are an effective alternative to cigarettes for nicotine users, but with very low health risks. They work because they deliver a satisfying and rapid dose of nicotine, some of the sensory experience and have similar behavioural rituals. This is very different from the function of NRT medicines, which deliver a slower background dose of nicotine to help relieve cravings during an effort to quit smoking and nicotine use completely. This is a fundamental difference: e-cigarettes are alternatives to cigarettes with a number of desirable characteristics for continuing nicotine users: much lower long term health risks; immediate benefits in well-being and quality of life; no second hand smoke impact on others; minimal fire risk; less mess and usually lower cost. These are substantial public health benefits and should be exploited. There is also increasing – though not yet conclusive – evidence that these products work as effective cessation aids, providing a staging point between smoking and complete withdrawal from nicotine for those who ultimately wish to quit completely.

The risks. E-cigarettes should not be assumed risk free, but given what is in them and how they are used they are likely to be very low risk relative to cigarettes – two orders of magnitude (about 99%) less hazardous would be a reasonable assumption based on what is known already. The most serious risk arises not from use, but accidental ingestion of nicotine e-liquids – and can be mitigated with tamper proof packaging. The FDA found that they can contain residual contaminants or nitrosamines – but so do NRTs and many foods at similar levels. The concentrations are at levels so low as to be of little concern. These risks are likely to be small and manageable compared to what we know of the burning hot tar particulates and toxic gases taken into the lungs through cigarette smoke.

The unintended consequences of a ban. The likely result of denying smokers alternatives to smoking that have proved effective and valuable elsewhere is more smoking than there would otherwise be, as people are unable to adopt strategies to quit or switch using these products. The proposal to ban e-cigarettes is a in effect a proposal to protect the incumbent cigarette industry from competition from high-tech alternatives with superior characteristics. Why would a government do that? A further likely unintended consequence would be growth of an unregulated black market. Israeli citizens or not stupid or passive about their health and would be likely to seek out supplies through internet sales – that might include legal products bought illegally or more dangerously, illicitly produced products made from mixing e-liquids or other home-made preparation.

The ethics of a ban. There is a liberal argument that goes like this: if people want to sell them, people want to buy them, they are much less risky than cigarettes and they comply with norms of consumer protection – like being acceptably safe, working as intended (ie not faulty), and as-described – then what is the ethical basis for a ban on e-cigarettes? Nicotine is a widely-used legal recreational drug that in itself is almost harmless, so why obstruct a much less dangerous way to take it with huge regulatory burdens that do not apply to cigarettes? When the state denies a smoker a product that could save their life, the state becomes complicit in the mortal consequences that follow from that decision. The are no precedents in other areas of consumer protection or health policy and no ethical basis for banning a much safer alternative to the dominant high-risk tobacco-based nicotine products.

What to do? The government should take the positive potential for e-cigarettes seriously, both for the beneficial effect it will have within Israel and for the signal it will send worldwide. There s potential to raise awareness and confidence in these products by establishing a framework of light touch consumer based regulation, covering electrical safety, tamper-proof packaging for e-liquids, correct disclosure of nicotine content and reasonable purity standards for e-liquids. Through the normal interplay of market forces, consumers will work out which products work, and these will become successful low risk alternatives to smoking. In most developed countries existing consumer protection law should be sufficient to achieve these modest objectives. Marketing should be permitted and efforts made to normalise these products as alternatives to smoking, by allowing their use in public places – and thus encouraging smokers to switch. If Israel does that, it will be in the vanguard of a modern liberal approach to tackling the burdens of tobacco related disease.

Disclosure. I have no competing interests. I have a long history of involvement in tobacco control starting in 1997, previously as director of Action on Smoking and Health (ASH-UK).  I was one of the main NGO leaders who helped to bring the WHO Framework Convention on Tobacco Control into being in the period up to 2003. I have retained an interest ever since, though I have been working as a civil servant for the last ten years. Please be assured my sole interest in writing to you is in reducing the burden of tobacco-related disease and death in Israel, Europe and globally. These views do not necessarily represent the current views of any of my previous employers.