Comments on Clive Bates' latest letter to WHO

Several people have asked me what I thought of the letter Clive Bates and three other people sent to Dr Tedros Adhanom Ghebreyesus, the Director General of the World Health Organisation of September 4, 2018 complaining about WHO’s position on e-cigarettes and other tobacco industry “harm reduction products.”

The first thing that struck me is that there were only 4 signatories, compared to the 53 on a similar letter he sent to WHO back in 2014.  I have no doubt that, with a little more time, Clive could have lined up some more signatures, but the list of people who are still buying his ideas is shrinking as the evidence for the dangers of these products keeps piling up:

• Every study that has examined whether kids who start nicotine use with e-cigarettes are at increased risk of smoking has shown a strong positive effect.
• The evidence that e-cigarettes pose substantial cardiovascular and pulmonary disease risk is piling up.
• While some people do successfully quit smoking with e-cigarettes, for most people e-cigarettes reduce the odds of smoking cessation.
• While Bates and his friends, along with the tobacco companies, keep talking about “complete switching,” the dominant behavior remains dual use, with people using both products at the same time; the risks add.

A few specific statements in the letter warrant comment.

E-cigarettes and other alternative tobacco products “have one factor in common: they do not involve burning of tobacco leaf or smoke inhalation. It is smoke that causes the overwhelming burden of disease and there is no serious doubt that non-combustible products are far less harmful than cigarettes.”

It is not just the smoke (combustion) that causes the problem, it is the aerosol of ultrafine particles that cigarettes, e-cigarettes and heated tobacco products use to carry the nicotine deep into the lungs.  These ultrafine particles are dangerous in their own right and cause heart and lung disease.  E-cigarettes and other inhaled products also have a wide range of other chemicals, some at higher levels than cigarettes.

The letter quotes a paper by David Abrams (another of the 4 authors of the letter) as if it was some sort of official consensus document:

In the 2018 United States Annual Review of Public Health, the authors recognised the transformative potential to realise that goal:

A diverse class of alternative nicotine delivery systems (ANDS) has recently been developed that do not combust tobacco and are substantially less harmful than cigarettes. ANDS have the potential to disrupt the 120-year dominance of the cigarette and challenge the field on how the tobacco pandemic could be reversed if nicotine is decoupled from lethal inhaled smoke,

This is a disingenuous bit of self citation.  The same issue of the “2018 United states Annual Review of Public Health” also contained an article by David Bareham and me (based on a much broader review of the literature) that concluded:

Because e-cigarettes have been on the market for only a few years, the long-term population health effects are not known. Nevertheless, it is already clear that e-cigarettes are prolonging and extending the tobacco epidemic by reducing smoking cessation and expanding the tobacco market by attracting youth who would otherwise be unlikely to initiate tobacco use with conventional cigarettes. On the basis of the short-term effects that have been identified to date, e-cigarettes likely have cardiovascular and noncancer lung disease risks similar to those associated with smoking conventional cigarettes. Under most reasonable alternative use pattern scenarios, this is a high enough risk to lead to a net population harm even if some smokers switch to e-cigarettes. To minimize harm, e-cigarettes as well as the timing and location of their promotion and use should be regulated like other tobacco products.

Bates et al also quote the 2018 National Academy of Sciences, Engineering, and Medicine report on e-cigarettes, which states, “While e-cigarettes are not without health risks, they are likely to be far less harmful than combustible tobacco cigarettes.”  When interpreting this statement it is important to keep in mind that this paper was based on the literature a year earlier, and our knowledge of the dangers of e-cigarettes has been accumulating rapidly.  The NASEM report also noted that, at the time that it was prepared, there were no studies documenting long-term adverse health consequences. Now, as noted above, there are.  (The 2016 Royal College of Physicians report they also quote is even more out to date.) 

The European Association of Public Health has the most current summary of the evidence.

They also say, “We have also seen no compelling evidence that these products attract significant numbers of young people who would not otherwise have smoked,” even though the NASEM report that they quote draws a strong contradictory conclusion:  “There is substantial evidence that e-cigarette use increases risk of ever using combustible tobacco cigarettes among youth and young adults.”

The WHO, FCTC Secretariat, and many countries are acting prudently not to be stampeded into supporting these products.