World No Tobacco Day is on 31 May 2019. On the surface, it seems hard to quibble with the World Health Organisation (WHO) when it warns that tobacco smoke is harmful to the lungs, and to health in general. It certainly is, though I’m not convinced we need a special day to remind us of that.
However, in recommending strict regulations for vapes, also known as e-cigarettes or electronic nicotine delivery systems, the WHO is going beyond its mandate and against the evidence.
I’ve criticised the WHO before about exceeding its original remit to combat contagious diseases.
It now uses the term “epidemic” to describe a wide range of non-communicable health concerns, from smoking to obesity. Under this guise, it encourages member countries to impose authoritarian and sometimes draconian control over their citizens’ lifestyles. Meanwhile, the organisation is alarmingly ineffective at dealing with actual epidemics of contagious diseases, which was its original mandate.
Often, its recommended policies have no proven benefits, or actively cause harm.
A good example is the idea of a sugar tax, which the WHO advocates. Even making very generous assumptions, as the study on which the South African government based its justification for a sugar tax does, it will have a negligible impact on public health. Evidence from countries that imposed a sugar tax suggests that it does not achieve public health objectives, but does destroy jobs and economic value. Studies that claim a sugar tax works are easily debunked as deeply flawed.
In another example, the WHO has formally endorsed traditional and alternative therapies for which there is limited or no scientific evidence, and whose practitioners actively resist scientific methods of establishing efficacy and safety. This encourages patients to seek out chiropractors, acupuncturists, osteopaths, reflexologists, naturopaths, homeopaths, traditional healers or any number of other practitioners of therapies of questionable ethical legitimacy. Relying on such witchcraft and wizardry poses significant risks of unknown or undisclosed adverse effects, but also of causing harm by forgoing timely evidence-based medicine in favour of unproven alternative therapies. Some of these remedies also support practices that endanger rare plant and animal species.
Likewise, there are significant flaws in the WHO’s approach to tobacco control. As with its other interventions, it is autocratic and premised on strong government control over every aspect of tobacco, from its manufacture, advertising, sale and taxation to its consumption.
The organisation nailed its anti-democratic colours to the mast at the Sixth Conference of the Parties (COP6) in Moscow, Russia in 2014,when it unceremoniously ejected the public and the media from its deliberations about imposing a global tax on tobacco products.
Rules that protect non-smokers from the unpleasant and unhealthy smoke produced by smokers are laudable. In a free society, one’s right to do as one pleases ends where it begins to infringe on the same right of others.
The goal to discourage smoking does infringe on the individual right to take whatever risks they want with their own health in pursuit of a happy life. One might just as well prohibit skateboarding or mountaineering on the grounds that it poses risks to one’s physical health.
Supposing, however, that the effort to reduce smoking is legitimate, the WHO is advocating some policies that have no proven benefits, and others that actively cause harm. I recently wrote about the inconvenient fact that plain packaging, where it has been adopted, has failed to make any impact on smoking rates. It is an imposition with costs, but no benefits.
The WHO’s declared position on vapes is even worse. In its zeal to crack down on tobacco, it has gone beyond the mandate of the Framework Convention on Tobacco Control (FCTC), which enjoins member countries to monitor tobacco use and prevention policies, protect people from tobacco smoke, offer help to quit tobacco use, warn about the dangers of tobacco, enforce bans on tobacco advertising, promotion and sponsorship, and raise taxes on tobacco.
Its standing decision, dating back to 2014, recommends restricting the sale and banning the advertising of vapes. The WHO in 2016 claimed that these restrictions are justified by the lack of evidence of harm reduction and the ability of e-cigarettes to help tobacco smokers quit. This position is rather ironic, given how little concern it has for scientific evidence in the case of alternative medicines.
In a report to COP6 of the FCTC in Moscow in 2014, the WHO also warned that vaping may undermine existing efforts to “denormalise” smoking, and act as a “gateway” to tobacco smoking.
In its report to COP7, held in Delhi, India in 2016, the WHO maintained its negative view of e-cigarettes and continued to advocate strict regulation. At COP8, held in Geneva, Switzerland in 2018, the usual report on ENDS documented progress with regulation, but introduced no new evidence, merely noting that there was “no international scientific consensus” on either negative or positive impacts of e-cigarettes.
If there was indeed a lack of evidence at the time these statements were made (between 2014 and 2018), then there were no grounds for regulation in the first place. It is farcical to regulate that which is not known to cause significant harm.
Yet many governments, including that of South Africa, adopted the WHO recommendations without much critical engagement. The supposed socio-economic impact assessment on the Control of Tobacco Products and Electronic Delivery Systems Bill, for example, was more an advocacy document than an objective, evidence-based impact assessment.
As I noted in 2018,it failed to justify the amendments to the law, and ignored the people who would be most seriously affected. The Bill proposes to treat vapes — even those that do not contain nicotine — as tobacco products, as recommended by the WHO.
In 2014, it was true that few studies had been conducted, which resulted in low confidence in their results.
Even so, as early as 2014 an independent review of the literature found that vaping does help smokers to quit, helps heavy smokers to reduce their cigarette consumption, and was not associated with significant adverse events. Two years later, an expansion of that reviewcame to the same conclusions. That same year, 2016, a study in the UK found that e-cigarettes were positively correlated with the success of quit attempts.
Several more recent studies have confirmed these findings, in what is becoming a mountain of evidence that contradicts the justifications for the WHO recommendation to restrict and regulate vaping.
A 2017 study funded by Cancer Research UK found “substantially reduced levels of measured carcinogens and toxins” in vapers, compared to smokers. Another 2017 study found that e-cigarette vapour contains less than 1% the carcinogens present in tobacco smoke. A study of over 60,000 teenagers in 2017 found that most e-cigarette experimentation does not turn into regular use, and levels of regular use in young people who have never smoked remain very low.
Public Health England (PHE), a government agency, in 2018 reconfirmed its position that vaping is 95% safer than smoking, and poses negligible risk to bystanders.
It also found that the addictiveness of nicotine is enhanced by the other compounds in tobacco smoke, which makes vaping less addictive. It found that e-cigarette use is rare among never-smokers, irrespective of their age, and most of those do not progress to regular use.
It found there is no causal link between vaping and smoking, and e-cigarettes do not appear to be undermining the long-term decline in cigarette smoking in the UK among young people. It found that vapers were more motivated to quit smoking than other smokers, quit success rates were at record highs in 2017 and that e-cigarettes contributed to tens of thousands of additional quitters in England.
It also found that people are widely misinformed about the relative safety of e-cigarettes. Only half of smokers believe that e-cigarettes are safer than tobacco, even though it is objectively much less dangerous. The WHO’s scaremongering undoubtedly plays a role in this misperception.
“It would be tragic if thousands of smokers who could quit with the help of an e-cigarette are being put off due to false fears about their safety,” Professor John Newton, director of health improvement at PHE, told The Guardian.
The organisation strongly supports the promotion of e-cigarettes to help smokers quit, and even recommends that the devices be sold in hospital shops.
“We want stop-smoking practitioners and health professionals to support smokers who would like to use e-cigarettes to stop,” Ann McNeill, lead author of the review and professor of tobacco addiction at King’s College London, told the paper.
A study published in February 2019 found that e-cigarette users were almost twice as likely (18%) to quit successfully as people who used traditional nicotine-replacement therapy (9.9%).
Another recent study found that the use of e-cigarettes was not associated with a renormalisation of smoking, even during a period of rapid, unregulated growth in the availability and use of e-cigarettes, and that fears of a resurgence of tobacco smoking among teenagers as a result of vaping were unfounded.
The evidence keeps piling up against the authoritarian WHO approach to tobacco control. Some of its recommendations have no effect, such as the move towards plain packaging, and other recommendations are actively harmful to the objective of getting smokers to quit, such as its stance on e-cigarettes.
The WHO’s determined opposition to harm reduction when it comes to tobacco use also stands in stark contrast to its policies regarding other public health concerns, such as HIV/AIDS and intravenous drug use, in which it favours harm reduction strategies.
It is clear that we cannot rely on our own government to correct the mistakes of the WHO. On the contrary: The South African government is barreling right ahead with laws to restrict the sale and advertising of e-cigarettes as if they were tobacco products, despite the mounting evidence that they substantially reduce harm by comparison with cigarettes, pose negligible risk to bystanders, are more effective as quitting aids than anything else on the market and do not lead to, or renormalise, tobacco smoking among the youth.
The WHO ought to have more consideration for scientific evidence, and more concern for the people who are affected by its misguided decisions.
On this World No Smoking Day, the WHO should publicly and loudly reverse its negative stance on e-cigarettes, and instead recommend that their sale and use be encouraged by all possible means. The scientific evidence demands no less. DM
This article was updated on 29 May, 2019 to restore the links that disappeared during the editing process.
"Authority without wisdom is like a heavy axe without an edge - fitter to bruise than polish." ~ Anne Bradstreet