Dr Adrian Payne is the Managing Director of Tobacco Horizons, a Tobacco Harm Reduction Consulting Agency. During a post-doctoral career spanning more than thirty years, he has worked for both tobacco and pharmecutical companies, often in the field of Tobacco Harm Reduction.

ECD: How harmful is the electronic cigarette when compared to a regular cigarette?

Adrian: Based on the safety profiling data on E-cigarettes that has been published so far, I think it’s reasonable to say that they are probably at least two, if not three, orders of magnitude less harmful than regular cigarettes. The key reason for this huge difference is that E-cigarettes don’t generate harmful tobacco smoke. But it’s important to understand that ‘no smoke’ doesn’t necessarily translate into ‘no harm’; it’s possible that some risks might emerge from studies into their long-term use.

However, it’s hard to imagine that any such risks would even begin to approach those of smoking cigarettes. Indeed, probably the issue of main concern with E-cigarettes is that children might ingest the E-cigarette cartridges. So along with the necessary internal quality control checks, it would seem sensible for the various manufacturers to use childproof packaging as a design feature.

ECD: Do we have any idea of the effect of heating up nicotine prior to inhaling it? How is the heating of nicotine by the electronic cigarette different to setting fire to tobacco and inhaling the resultant smoke?

Adrian: The end result of tobacco combustion and nicotine vaporisation is basically the same, i.e. generation of a nicotine-containing aerosol that can then be inhaled by the user. Both processes involve heat, but they are otherwise very different in that the aerosol generated by the E-cigarette does not contain within it the thousands of other chemicals, many of which are thought to be extremely harmful, that result from the combustion of tobacco. It’s true that concerns have been expressed about possible harmful effects of some of the chemical components other than nicotine in the E-cigarette aerosol, for example propylene-glycol. But based on current knowledge, these concerns seem vastly overplayed when compared to the risks of cigarette smoking.

ECD. One criticism that has been leveled at the e-cigarette is that it could encourage youngsters and other non-smokers to take up smoking. Are young people more likely to take up smoking with an electronic cigarette than with a regular cigarette?
I’m not aware of any evidence of adult non-smokers using either E-cigarettes ...in any number as a gateway to smoking – if there were I’m sure we would have heard of it by now. Bad news travels fast!

Adrian: As a parent myself, I understand concerns that young people might be attracted to E-cigarettes and then move on to conventional cigarettes. But I’m not aware of any evidence that this is, or is even likely to be, the case. In the first place, E-cigarettes are not ‘pocket-money’ devices. Secondly, I don’t think anyone has raised the same concerns about pharmaceutical nicotine inhalators which, in the UK at least, are available over the counter. Similarly I’m not aware of any evidence of adult non-smokers using either E-cigarettes or pharmaceutical nicotine inhalators in any number as a gateway to smoking – if there were I’m sure we would have heard of it by now. Bad news travels fast!

ECD: You have worked with both the tobacco industries and the pharmaceutical industries. Do you think there is any justification in e-smokers’ beliefs that Philip Morris is interested in snuffing out alternatives to cigarettes via the Tobacco Bill it supports in the US? And are large pharmaceutical companies encouraging public health groups in America to campaign against the devices?

Adrian: To my knowledge, Philip Morris was involved in discussions on the Tobacco Bill it supports in the US long before the advent of E-smoking so I don’t think that these beliefs are justified in the case of E-cigarettes. But what I think are justified are the widely-held beliefs that if this Tobacco Bill is signed into law as currently drafted, E-cigarettes along with other innovative products would face an almost impossible task to get regulatory approval and would therefore be banned.
"E-cigarettes are at risk of being caught in a regulatory trap, with consumers being denied the choice of a far safer product than regular cigarettes..."

This would in effect freeze the market and divide it between regular cigarettes (for those who either want to smoke or partake in the quasi-smoking experience which E-cigarettes provide), smokeless tobacco products (less harmful than cigarettes, but a completely different consumer experience) and pharmaceutical nicotine products (for those want to quit smoking entirely or at minimum cut-down their consumption). So E-cigarettes are at risk of being caught in a regulatory trap, with consumers being denied the choice of a far safer product than regular cigarettes that might meet their smoking abstinence needs better than either smokeless tobacco or pharmaceutical nicotine products.

It would make a lot more sense if a separate regulatory category were to be carved out for cross-over products like E-cigarettes and I’d like to see the manufacturers of these products being more pro-active in this regard. I’m certain such a move would find support from those members of the public health community who see E-cigarettes as potential life-savers rather than as regulatory upstarts. Development and application of an appropriate regulatory package wouldn’t have to be done all at once; it could be incremental, thereby allowing the products to stay on the market in the meantime.

Certainly large pharmaceutical companies with interests in stop-smoking medicines provide very substantial financial support to some of the public health groups that are calling for E-cigarettes to be banned. Incidentally these are the very same public health groups that support the Tobacco Bill backed by Philip Morris. But I’m not aware of any evidence of specific encouragement from these pharmaceutical companies for those groups to take such an antagonistic position. Nor have I seen any position statements on E-cigarettes from the companies themselves. That doesn’t mean to say of course that they are not keeping a close eye on what is happening on the E-cigarette front – I’m sure they are!

ECD: The reaction in the UK seems to be that these devices might help, but that more research is needed. Should more research be done into electronic cigarettes before we allow them to be used by smokers?
"...current smoking prevalence rates are proving surprisingly stubborn to conventional public health interventions."

Adrian: Well, it’s certainly good that some commentators think that E-cigarettes might help; current smoking prevalence rates are proving surprisingly stubborn to conventional public health interventions. Apart from the reduced harm aspect, E-cigarettes do offer that touchy-feely behavioural aspect of cigarettes that for the most part other alternative products don’t. When it comes to the need for more research, I agree with this, but it should not be at the expense of taking the products of the market in the meantime. If this were to be the case, it really would be a cruel irony if smokers who had switched to E-cigarettes were, as a result, forced to revert to smoking regular cigarettes.

ECD: Should health groups help to fund this expense, as they should also be un-biased. Also, should the e cigarette be taxed by the government to compensate for potential loss in revenue?
"I’d hope that governments would use tax policy to steer smokers towards safer products rather than drive them away from them."

Adrian: At a time of economic crisis when many health groups are under financial pressure, the funding may have to come from elsewhere. But it would be entirely appropriate, if not essential, for health groups to be involved in the design of protocols and the undertaking and review of research to evaluate more fully the long-term potential of E-cigarettes as less harmful alternatives to cigarettes. Yes there might be a revenue loss from fewer cigarettes being smoked if E-cigarettes took off in a big way. But I’d hope that governments would use tax policy to steer smokers towards safer products rather than drive them away from them.

ECD: The current advice for smokers from bodies like ASH UK is that nicotine replacement aids should be used by smokers instead of electronic cigarettes. How effective are these aids in helping smokers give up over the long term?

Adrian: Nicotine replacement aids clearly work for some people, but overall these aids are much less effective than one might anticipate, especially over the long–term. For example, in a recent study they were found to be effective in only 1.6% of users, although this admittedly this was better than the 0.4% achieved with placebo treatment.

It’s of course feasible that the development of newer nicotine replacement aids that more closely reproduce the pharmacokinetic profile of the intake of nicotine from cigarettes might improve on this, and currently there is a lot of interest in testing this concept. But at the end of the day it seems the most important thing that helps smokers to give up is having the willpower to do so. If E-cigarettes prove over time to be an effective transition tool in enabling smokers thinking about quitting to develop and build on the willpower to help them do so, then it would be an obvious benefit. I’d hope that if this is the case, bodies like ASH UK would recognise it as such and respond positively by revising their advice accordingly.

ECD: Of course, e-cigarettes are not the only alternative to smoking. Snus is regarded as one of the safest alternatives and some experts we have interviewed believe it contains no measurable risk at all. In your opinion, has the banning of Snus caused the death of smokers in the UK?
"...the reasoning for maintaining the ban [on snus] seems more political than scientific...Quite bizarre really!"

Adrian: Times have changed since the EU ban on snus was originally imposed and even hard-line tobacco control advocates now acknowledge that snus is much safer than cigarettes. So the reasoning for maintaining the ban seems more political than scientific, especially given that some smokeless products that are potentially much more harmful than snus are legally on sale. Quite bizarre really!

Perhaps the best answer would be to replace the specific EU ban on snus with a comprehensive overhaul of EU tobacco and nicotine regulation. I’d hope that this would put all nicotine-containing products under the same regulatory umbrella, classify them according to risk, and ensure that consumers are informed accordingly so that they can self-regulate their risk.

To get back to your question, according to one study over 200,000 premature deaths might be avoided annually in just fifteen EU countries if smoking rates were as low as in Sweden, which is attributed in large part by many observers to the Swedish preference for snus instead of cigarettes. So intuitively, it’s very tempting to say ‘yes’. However, without snus having been on sale legally in the UK it’s not really possible to give a definite answer. This is because we don’t know what the UK consumer reaction might have been to snus being made available as an alternative to cigarettes.
"...public health backing, rather than criticism, of the launch of such products can play a vital role in getting the message across to the consumer, even if these products originate from the tobacco industry."

It’s not sufficient to just put a less harmful product like snus on the shelves in the hope that consumers will buy it; it has to have consumer relevance and sufficient utility to stimulate trial and repeat purchase. The same is of course true for E-cigarettes and any other less harmful cigarette-alternative. This is where public health backing, rather than criticism, of the launch of such products can play a vital role in getting the message across to the consumer, even if these products originate from the tobacco industry.

ECD: Do you see parallels between Snus and E-Cigarettes?

Adrian: Absolutely, there are definite parallels here. Both products offer smokers nicotine-providing alternatives to cigarettes at a vastly reduced relative risk, primarily because of users not having to inhale tobacco smoke. Both products also offer the consumer some elements of the ritualistic aspects of smoking that medicines don’t. And Sweden offers a good example of how preferences have changed when consumers are given the choice. That doesn’t mean to say that either type of product would necessarily have a universal attraction for smokers. But even if only a small minority of smokers switched, the public health benefits could still be considerable.

"Prohibition didn’t work for alcohol in the US and I see no reason why it should work for tobacco either."

A regrettable parallel is that the opposition of some to cigarette alternatives such as snus and E-cigarettes seems to be born out of an absolutist view that the use of tobacco products (or anything resembling them) should be eradicated from modern-day society. Prohibition didn’t work for alcohol in the US and I see no reason why it should work for tobacco either. Some detractors claim that making cigarette alternatives like snus and E-cigarettes available encourages dual-use in combination with cigarettes and thus delays quitting smoking. But the same criticism could equally well be directed towards medicinal nicotine products marketed to relieve cravings during temporary abstinence from smoking.

Finally, I’d say that the current controversy about both snus and E-cigarettes is indicative of the fact that current models of tobacco and nicotine regulation have outlived their usefulness. Urgent revision is required to help, rather than hinder, consumers being able to make healthier choices if they either don’t want to, or can’t, quit their nicotine dependence entirely. E-cigarettes and the voices of the many E-cigarette users world-wide could prove to be a powerful catalyst for change in this regard; as someone who has long had a passionate interest in tobacco harm reduction, I certainly hope so!