Commentary on who report on Electronic Nicotine & Non-Delivery Systems

The World Health Organisation has commissioned a scientific assessment and policy options report on electronic cigarettes (referred to in the report as Electronic Nicotine Delivery Systems (ENDS) and Electronic Non-Nicotine Delivery Systems (ENNDS)) for the Seventh Conference of the Parties of the Framework Convention on Tobacco Control (FCTC COP-7). This paper provides a critique of that assessment. The main concerns with the WHO report are as follows:


Positioning ENDS as a threat rather than opportunity. Overall, the WHO report does not correctly position ENDS primarily as an alternative to smoking and instead focusses excessively on risks of ENDS use without adequately recognising the deep reductions in health risks when a smoker switches to ENDS. The FCTC itself recognises ‘harm reduction’ as a key strategy in tobacco control. But with minor exceptions, the WHO report discusses ENDS as a threat, whereas in fact they represent a major opportunity for public health.
Failure to quantify risk. The WHO paper provides a poor assessment of ENDS risks. In terms of toxicology, the discussion is naïve and places excessive emphasis on negligible risks arising from very low exposures. In toxicology, the presence of a potentially harmful agent does not necessarily establish a material risk. This is because the level of exposure matters and “the dose makes the poison”.
Inadequate comparisons with smoking. The WHO paper does not systematically make meaningful comparisons with exposures arising from inhaling tobacco smoke or refer to other useful comparators such as occupational exposure limits. However, data from around the world shows that almost all ENDS users are smokers, ex-smokers or would-be smokers. The most relevant comparison for health policy purposes is with smoking.
Misrepresenting second hand ENDS vapour risks. The section on risks of second-hand exposure to ENDS aerosol provides no evidence that such exposures pose any material risks to bystanders. The claim that ENDS have the “potential to lead to adverse health effects” in bystanders does not reflect the science behind the cited source unless ‘potential’ is taken to mean any exposure, no matter how trivial. Again, the issue is not the presence of particular chemicals, but the magnitude of exposure.
Discounting the evidence that ENDS do help smokers quit. The WHO paper does not properly assess the role that ENDS play in quitting smoking and uncritically repeats a number of methodological errors found in the literature. Taking the totality of evidence including controlled trials, observational studies, changes in population smoking and ENDS use, the experience of nicotine replacement therapy, and widely reported user experience, there is confidence that ENDS are helping many smokers to quit smoking and not having negative effects like renormalising smoking, reducing quit rates or creating gateway effects.

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