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NICE guidance on tobacco harm reduction - electronic cigarettes barely figure

The UK's National Institute for Health and Care Excellence (NICE) today issued its guidance on "helping people who can't quit smoking in one step". In other words, Tobacco Harm Reduction.

Any hopes that they might promote electronic cigarettes in this guidance have been dashed - the text endorses only "licensed products", specifically gum and patches.

Where e-cigarettes are mentioned, it is in the context of guidance for health advisers. They are informed that they should tell consumers that the quality, safety and effectiveness of e-cigarettes cannot be guaranteed, but that they are likely to be less harmful than cigarettes. Opinion will vary on this particular point - on the one hand it is true when taken literally, but as Prof. John Britton has said "if it's a choice between cigarettes and e-cigarettes it's a no-brainer" - in other words, any honest assessment of risk has to come down heavily in favour of e-cigarettes versus tobacco smoking.

In a sense, then, I take this as a positive, especially when one considers the type of conversation that is likely to occur between a smoker and an 'adviser' - in reality, as e-cigs get better press, advisers have essentially been given license to endorse e-cigs over cigarettes, and this is a good move forward.

However, there are a few very large elephants in the room.

Firstly, and this to my mind is the biggie, this guidance does nothing for the millions of smokers who don't believe they have a medical disorder (nicotine dependence), and have no intention of giving up smoking. The guidance is specifically for those who 'can't quit' - not those who 'don't want to quit'. The real wonder of e-cigarettes is that many vapers start vaping for reasons unrelated to quitting (economic, convenience), but end up quitting because it's a superior experience. Unfortunately, the big assumption behind this guidance is that enough smokers have the motivation to stop smoking using advice/products recommended or given to them by medical authorities. I'm sorry, but I just don't see any evidence for this. That's not to say that it won't be a great solution for many smokers, but it sweeps under the carpet the real issue: smokers need a thriving market in safer alternatives, not to be ushered into the medical landscape and offered licensed products, just because the medical establishment insists on it.

Secondly, the Royal College of Pharmacists have long been calling for people to be offered products which give them a high dose of nicotine to help them successfully stop smoking. However, it's now clear that nicotine itself is not the only thing that smokers want, although it is important (and, contrary to popular opinion, it does work for many). E-cigarettes have shown, beyond doubt, that most smokers need products which closely mimic the sensory aspects of smoking - this is reflected in the psychological theory, by the way, and should come as no surprise to medical authorities.

Thirdly, it is now clear that nicotine is viewed by the NICE as being relatively harmless, and this is a very good thing. In particular, it should go a long way in dispelling the mythology that has arisen regarding nicotine being the principal cause of harm - although little is mentioned about its addictiveness (or lack thereof) outside the context of tobacco smoke - probably because no-one really knows!

Lastly, the real implication of this text seems to me that the MHRA will announce soon that it intends to regulate e-cigarettes as medicinal products. An MHRA announcement is said to be due in "Spring 2013" (i.e. now), so watch this space. I hope that they offer a medicinal licensing option for those who wish to persue it, rather than mandating that all nicotine containing products be licensed, but who knows.

A final point to make is that NICE have been told for many years that THR is necessary. The RCP issued its opinion in 2007, and in the 6 years since little has happened, barring some allowance made for NRT makers to market their products more strongly. This lack of action has arguably cost many lives. Further, 2013 is a big year for vaping - it's the year that it's really going mainstream, and I would say that this upstart product has really focused minds at NICE, so in a sense this could be regarded as a victory.

What does this mean for the worldwide situation? Quite a lot, I would say. NICE is an important organization, well regarded internationally and their opinion will count strongly when other regulatory authorities come to issue their own rulings. On the one hand, the positive move towards harm reduction will alter the regulatory landscape. On the other hand, the fact that smokeless tobacco and, currently, electronic cigarettes are not part of the proposed solution should worry those of us who wish to continue to use these products, and those of us who wish to see smokers not yet using them gain access in the future.

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