Tobacco Industry 'On the Run': But E-cigs Opening a Door?

Zosia Chustecka

April 03, 2014

GENEVA — Great strides are being made in the public health battle with big tobacco companies, but a new form of smoking — electronic cigarettes — threatens those victories, said an expert here at the European Lung Cancer Conference 2014.

"We have got the tobacco industry on the run and we have to keep them running downhill," declared epidemiologist and cancer prevention advocate Peter Boyle, Dsc(Med), PhD, president of the International Prevention Research Institute in Lyon, France.

Dr. Peter Boyle

In an education session on epidemiology, Dr. Boyle traced the history of cigarette smoking, and how it created an epidemic of lung cancer. He pointed out that in 1912, lung cancer was described as one of the rarest tumor types. It has since become the most common cancer, within the space of a century.

Dr. Boyle also reviewed current tobacco control policies, and highlighted in particular the effectiveness of banning smoking in public places.

He noted that a recent review of data from Ireland (PLoS One. 2013;8:e62063), which was the first to introduce such a ban 10 years ago, highlighted the deaths from secondhand smoke that have been prevented, and concluded that while tax increases, health warnings, and advertising bans "may have resulted in synergistic health improvements," their effects have "been small and gradual" compared with the impact of the ban on smoking in public places.

"We are making tremendous strides in the war against cigarettes, which will eventually turn into a victory in the war against lung cancer," he said.

However, he sounded the alarm over electronic cigarettes, which are increasingly popular among youngsters, and which he fears are opening a "gateway to smoking."

Concern Over Increasing Popularity of E-cigs

A spokesperson for the European Society of Medical Oncology, which organized the conference, agreed that e-cigs are a concern.

"Over the last few years, smoking bans in public places, packaging, and media campaigns have tried to discourage smoking and increase awareness about smoking-related morbidity and mortality," commented Raffaele Califano MD, consultant medical oncologist at the Christie NHS Foundation Trust and University Hospital of South Manchester, United Kingdom.

But he points out that e-cigs are "now allowed in public places and are commonly seen as a 'safe' alternative to tobacco smoking or as a way to quit."

"These devices are currently unregulated and there is no restriction for sale to minors," he commented to Medscape Medical News. "As a result, more and more teenagers have started using electronic cigarettes and members of the public consider these devices an effective method for smoking cessation."

"Increasing use of e-cigs is concerning for a number of reasons," Dr. Califano commented. "First of all, the evidence to support the use of e-cigs as smoking cessation devices is largely inconclusive. Second, there are very few data on potential harm due to long-term use. Most important, they can visually reinforce the message that smoking is a good thing and therefore reduce the efficacy of all smoking cessation campaigns."

In the United States, the Center for Disease Control and Prevention (CDC) has raised concerns over the rapid growth in the use of e-cigs, particularly among teenagers. The battery-operated devices deliver nicotine and other substances in an aerosol, often with a flavoring that appeals to youngsters. Last year, CDC director Tom Frieden, MD, MPH, warned: "Nicotine is a highly addictive drug. Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes."

Smoking Used to Be Commonplace

In his lecture, Dr. Boyle traced back the popularity of smoking to the 2 World Wars (1914 to 1918 and 1939 to 1945), when cigarettes were included in daily rations for military personnel in the British, American, and German armies.

"Smoking became a very common practice, and the industry grew rapidly," he commented.

There were persuasive media campaigns, some even in medical journals featuring doctors attesting to the benefits of a particular brand.

The tide started turning around 1950 to 1953, when smoking was at a peak, with the publication of the first reports linking smoking to lung cancer, and then 1964 saw the publication of the US Surgeon General's report on smoking and health.

With the realization that smoking was damaging to health came the first attempts at public health activity against smoking, including warning labels on cigarette packages.

But the backlash was "nearly a half century of the tobacco industry engaging in lies, deceit, cover up, and smoke and mirror obfuscation," Dr. Boyle said.

"As the twentieth century drew to a close, the world was coming to terms with a product, which when used as the manufacturer intended, leads directly to immense and immeasurable pain and suffering and premature death among its consumers."

Tobacco Control

Tobacco control is now popular field to work in, but when it began 20 to 25 years ago, it was not, and the people who pioneered this field were "very brave" he said.

Tobacco control policies have evolved over time, with a continual struggle between the tobacco industry and public health authorities, he said.

Public health is now winning — the market is decreasing, and smoking prevalence has fallen in many, but not all, developed countries, Dr. Boyle said.

Some of the change has been rapid. From 1997 to 1999, world tobacco leaf sales went from 7,975,360 tonnes to 6,341,430 tonnes, and world cigarette production went from 5,614,830 million pieces in 1996 to 5,573,464 million pieces in 2000.

And some of the declines in smoking have been dramatic. For example, in the United Kingdom in the 1950s, 80% of men were smoking, but this had fallen to less than 40% by 1990. The latest figures from the CDC show that smoking had fallen in the United States to 21.6% of men in 2010.

The result has been a decrease in lung cancer mortality — which peaked in British men in 1960, at which time 20% of all the men smoking were dying from lung cancer, but has been falling ever since.

"But if public health is winning, it is winning very slowly, Dr. Boyle said.

"We now know that to be effective, tobacco control must be comprehensive and global," he said.

"The tobacco industry's documented history of subverting control efforts has required innovative approaches," he said, and cited, as one of the most important of these, the World Health Organization (WHO) invocating its constitutional authority to develop treaties.

He described as " tremendously important" the WHO Framework Convention on Tobacco Control, which was adopted by WHO member states in 2003. In the decade since, 177 countries have ratified and started to implement its full provisions.

European Lung Cancer Conference (ELCC) 2014. Presented March 26, 2014.

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