La Recomendación a Favor de Cigarrillos Electrónicos

Los beneficios del cigarrillo electrónico para un fumador son innegables y su evolución como producto alternativo ha crecido a pasos agigantados, al punto que, desde la perspectiva de un fumador, la diferencia es muy poca. Proveé una alternativa, que por su composición química, forma, y conducta, apoya al fumador a convertirse en un ex-fumador, dejando los cigarrillos de tabaco atrás. 

La Administración de Alimentos y Drogas (el FDA) de las Filipinas está tomando una perspectiva racional - debatiendo los méritos del cigarro electrónico como una alternativa atractiva para fumadores. Clive Bates, que fue director de una ONG anti-tabaco por muchos años en Inglaterra y parte del movimiento de control de tabaco, escribió una carta abierta al gobierno de las Filipinas exponiendo su posición y apoyo al cigarrillo electrónico como una alternativa. 

Es un paso hacía asegurar la disponibilidad continua de un concepto que ha ayudado a millones de personas alrededor del mundo a dejar de fumar cigarrillos de tabaco y mejorar la calidad de sus vidas. 

July 24, 2013
Dear Dr. Hartigan-Go
I am writing to urge the Philippines government to take a positive approach to e-cigarettes. Any move to ban these products or to restrict them excessively would be harmful to public health in the Philippines. It would also send a terrible signal to many countries in the region. Any decisions taken by the government will be of international significance, and with your permission I would like to represent a view 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 many OECD countries 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 an area where there is good science now. 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 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 from trials that these products work as effective smoking 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 of the United States 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. There is no evidence that these products appeal to children - but even if they did, they may be used as and alternative to smoking and in any case cause minimal harm. The claim that they 'renormalise' smoking has no basis - the use of e-cigarettes in public places has the beneficial effect of normalising a much safer alternative to smoking. There is no basis for restricting by law the use of e-cigarettes in public places or workplaces - the products do not cause harm to third parties. At the same time there should not be a right to use them anywhere - it is up to the operators and owners of public places and workplaces to decide, and not for the government to impose regulations. 
The unintended consequences of a ban or excessive regulation. The likely result of denying or limiting 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. Any proposal to ban or excessively restrict e-cigarettes is in effect a proposal to protect the incumbent cigarette industry from competition from high-tech alternatives with superior characteristics. Why would the Philippines government do that? A further likely unintended consequence would be growth of an unregulated black market. Citizens are not stupid or passive about their health and would be likely to seek out supplies through back street or 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 strong argument to leave these products to develop as rapidly as possible and to take market share from cigarettes. 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 not described in a misleading way – then what is the ethical basis for a ban or excessive restrictions 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 the Philippines and for the signal it will send worldwide. There is 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 the Philippines does that, it will be taking a modern, forward looking approach to 'harm reduction' - that will be good for health and establish the Philippines as an international leader.
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 the Philippines and globally. 
I would be delighted to assist you further in your efforts to define policy for e-cigarettes and thereby to secure the best public health outcome for the Philippines. 
Yours sincerely 
Clive Bates
Counterfactual Consulting 
+44 77 6879 1237