E-cigarettes – the key to smoking cessation in LMIC?

Blog 25 Sep 2019

The first week of lectures on the DTM&H already feel distant, but I will not forget the shocking statistics on how much cigarette smoking contributes to the global burden of disease. For instance, COPD is projected to be the third greatest cause of global mortality in 2020 (behind ischaemic heart disease and cerebrovascular disease, both of which of course have their own links with smoking). I was also surprised to learn that LMIC are disproportionately affected; in fact 90% of COPD deaths are in low and middle income countries. In high income countries, increased prevalence among poorer people is potentially a significant driver of health inequality within society. 

One of my first medical jobs was on a respiratory ward; the impact of smoking-related disease on patients’ lives made a strong impression. There were always several COPD patients, at times unable to walk unaided or speak due to overwhelming breathlessness. More than once I felt like all the knowledge, training and resources at my disposal had incredibly little to offer the patients on my ward.  I can’t imagine how patients manage in countries where resources are scarce and hospital transport, home oxygen, community chest physio and so on are lacking. The concept, well expressed by Sir Michael Marmot, that medicine is no more than failed prevention, never felt so relevant. 

It is, therefore, no wonder that the medical community has been so interested in the potential of vaping to tackle the rise in smoking-related mortality and morbidity. Finally, there exists an alternative to smoking which is acceptable to the public and could push quit rates above a relatively static 50% (in the UK over the last 10 years). There are some sticking points: several accusations that marketing campaigns were aimed at younger people and non-smokers (although vaping is illegal for under 18s) and concerns that vaping may in fact act as a gateway to smoking. Nevertheless, an evidence review by Public Health England found that vaping poses only a small fraction of the risks of smoking, and switching completely from smoking to vaping conveys substantial health benefits, as well as reducing risk of harm to bystanders. The review also found that there is no evidence that vaping is a gateway to smoking in young people - an association exists between vaping and smoking, but no causation could be proved. Furthermore, in the UK, the rate of vaping remains very low among 11-18year olds, with only 1.7% reporting at least weekly use (2018). 

So if the evidence in the UK supports vaping as an alternative to cigarette use, then what is happening in the USA? Across 38 states, there has been an outbreak of 530 reported vaping related cases of lung disease (67% of whom were aged 18-34yrs) with seven deaths. Currently, the CDC reports that “no single substance or e-cigarette product has been consistently associated with illness”. A lack of regulatory standards in the USA means a variety of contaminants or problems with faulty devices, could be responsible. The prevalence of vaping in the USA is also much higher than the UK, with 25% of 12th graders reporting use in the previous 30 days. 

And what are the implications for LMIC where smoking-related morbidity is growing? India recently announced a ban on e-cigarette sales in response to the USA situation and concerns of a ‘youth epidemic’ of vaping. In the UK, however, vaping can be a useful tool on a population and individual level. Indeed, Public Health England goes as far as to recommend that e-cigarettes are sold in hospital shops alongside nicotine gum and other smoking alternatives. In fact, even while investigations continue in the USA, the CDC continues to recommend that individuals using e-cigarettes for smoking cessation should continue to vape rather than return to cigarette use. 

What will be the response of LMIC to the growing use of e-cigarettes? It will be several years until there is evidence on the long-term effects of vaping, but it is likely that policy will need to be developed before this time. 

Even in the few years, I have worked as a doctor, many patients have asked me whether I would recommend vaping as an alternative to cigarette use. In the UK, there are clear guidelines and industry standards which have to be upheld. How would I respond if I was asked this question in a country where such safeguards are not present?  E-cigarettes have the potential to be an incredibly helpful smoking cessation tool in LMIC, but perhaps only if the governmental legislative power exists to maintain a high standard of product, and there are the health surveillance systems in place to detect adverse events.