Author's Note: On June 2nd, the New England Journal of Medicine published a case vignette, "A man considering the use of E-cigarettes." the following piece, which was written earlier, provides valuable guidance to physicians seeking to answer the NEJM's question.
England's Royal College of Physicians (RCP) recommended on April 28th that doctors "promote the use of e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK."
This comes less than a year after a review of the scientific literature by Public Health England found that e-cigarettes are 95 percent less harmful than smoking.
Yet in the U.S., new FDA regulations will obliterate chances of smokers using e-cigarettes to quit. At the same time, leading public health groups including the American Heart Association, the American Lung Association and the American Cancer Society are actively lobbying against e-cigarettes and distorting the science about both the safety of e-cigarettes and how they can help cigarette smokers dramatically reduce their risk, as the RCP put it by providing, "nicotine without the smoke."
It's no wonder that American doctors are doing a poor job helping their addicted patients make better decisions about how to get nicotine if they can't or aren't ready to get off of it completely. The thorough RCP report provides a stark contrast to the (at best) directionless guidance Americans receive from their doctors. This is a devastating dereliction of the medical profession's core responsibility of providing scientifically valid life-saving information to their patients who could use such advice to make informed choices about how to reduce their risk.
A conversation I recently had with a successful ophthalmologist illustrates the problem, but also suggest an opportunity to lay out a vision for how to provide better care for patients .
In a social setting, I asked the ophthalmologist how he counsels his patients about smoking, which, among other things, increases risk for cataracts and age-related macular degeneration. He told me he simply advises them to quit, because "the tar and the nicotine" are harmful. He's correct about the tar, a product of combustion, but the nicotine is not the culprit for smoking related eye-disease. I gently suggested that his patients have a right to more accurate information so they could make more fully informed decisions about their behavior.
This scenario suggests an urgent need for the American Board of Ophthalmology, the organization responsible for keeping their members current on science, to follow the RCP's lead. First, it needs to better educate ophthalmologists about how smoking does in fact damage eye-health, then it should provide standardized advice to provide patients based on the latest science, including the fact that e-cigarettes are 95 percent less harmful than smoking and can help smokers quit, thus reducing their risk.
Similarly, other physician speciality groups must immediately do a better job of educating their members and standardizing harm reduction advice. There's barely a body part or function which isn't compromised by smoking. In each practice area, doctors need to do a better job of educating their patients about the role e-cigarettes can play in helping them quit smoking. Physicians groups in each specialty area are uniquely positioned to serve their members when it comes to providing harm reduction advice.
Consider the field of mental health, where patients smoke at a much higher rate than the general population. Mental health providers must come clean with their patients and end the taboo on acknowledging the fact that nicotine does in fact provide benefits. There's no debate that nicotine is a stimulant, and that those who use it enjoy a range of feelings, from relaxation, sharpness, alertness, and a sense of calm.
For many, especially those with mental health challenges, those benefits help them get through the day. And the nicotine isn't making them sick, it's the delivery system that's the problem. The compassionate and science-based approach is to help patients understand why they smoke, and to discuss options, including risks and benefits of alternatives to smoking. Advising patients to use the nicotine gum or patch together with counseling is appropriate, even though for many, the delivery mechanism is ineffective because it doesn't even closely mimic smoking's nicotine delivery. E-cigarettes do.
From medical schools, to credentialing organizations, the entire American medical establishment needs to kick the habit of providing politically correct quit-smoking advice, and replace it with up-to-date medically validated harm reduction advice which includes e-cigarettes. They should do so as if their patients' lives depend on it, as the Royal College of Physicians has now made clear it does.
Jeff Stier is a Senior Fellow at the National Center for Public Policy Research in Washington, D.C., and heads its Risk Analysis Division.