Wednesday, March 15, 2017

New York State Department of Health Urges Physicians to Discourage Patients from Quitting Unless They Use Big Pharma Products and Tells Vapers They Might as Well Go Back to Smoking

The New York State Department of Health has sent out a letter to medical professionals in the state, urging them to discourage patients from quitting smoking using e-cigarettes, even if they indicate unwillingness or lack of interest in nicotine replacement therapy or other smoking cessation drugs.

In the February 2017 letter, the state health commissioner writes:

"I encourage all health care providers to talk to their patients -- young and old alike -- about the dangers of e-cigarettes and to discourage their use. For patients who are already using traditional cigarettes or e-cigarettes, there are currently seven FDA-approved medications for smoking cessation, including five nicotine replacement therapies."

Further, in a letter sent to VapeNY five days ago, the director of the state health department's chronic disease prevention division castigates vapers by denying that switching from smoking to vaping has any public health value, thus telling vapers that they might as well return to cigarette smoking.

The director of the division writes:

"To date, the evidence on vapor products, electronic cigarettes and similar devices finds the products have no credible public health value in real world use...".

The Rest of the Story

I could hardly believe my eyes when I saw these letters. In the first letter, the New York state health department actually urges physicians to discourage patients from quitting smoking unless they are prepared to use nicotine replacement therapy, Zyban, or Chantix. For patients who have no interest in using one of those three products (or have used them and failed in the past) and wish to try quitting by switching to vaping, the official recommendation from the state of New York is to discourage these patients from using e-cigarettes to quit. In other words, physicians should essentially discourage such smokers from making such a quit attempt, since the reality is that they are not interested in using medication.

This advice to physicians to discourage quit attempts using e-cigarettes is unqualified. It does not say: "Encourage smokers to try an FDA-approved medication first, and recommend e-cigarettes only if that fails." It advises physicians to discourage e-cigarettes under all circumstances. Obviously, this includes the circumstance where the patient tells the physician that she has no interest in using Big Pharma products and instead, wants to try vaping.

This blanket recommendation is inappropriate and in my view, damaging. Essentially, smokers are being told that if they don't want to quit the way the health commissioner thinks they should quit, then they shouldn't even try. Clearly, this attitude from the state health department is going to discourage many quit attempts and therefore promote continued smoking by many.

The advice is particularly inappropriate because the scientific literature shows that smoking cessation medications only have a 10% success rate in the real world. Thus, 90% of smokers who take the health department's advice are going to fail, and thus remain smokers.

The existing evidence suggests that electronic cigarettes are at least as effective as nicotine replacement therapy. And newer products currently on the market are almost certainly more effective than the nicotine patch, since the products tested in the existing clinical trials were first-generation products with very poor nicotine delivery. The delivery of nicotine by vaping devices has increased substantially since that time, meaning that these devices are almost certainly more effective than the early products. But even those early products performed equally to the nicotine patch in the clinical trial setting.

The Department of Health's declaration that e-cigarettes have "no credible public health value" means that there must be no value in switching from smoking to vaping. The health department is essentially telling the millions of smokers in the United States who have done exactly that (quit smoking by switching to vaping), that they might as well return to smoking. After all, if vaping has no public health value, then why bother vaping? You might as well go back to smoking, and you haven't lost anything.

The problem is that this is patently false. There is abundant evidence that vaping is much safer than smoking and that smokers who switch to vaping experience an immediate and dramatic improvement in their health, especially in respiratory symptoms and lung function. Several studies by Dr. Riccardo Polosa and his colleagues have demonstrated significant improvement in respiratory symptoms and objectively measured lung function (spirometry) among smokers who switched to electronic cigarettes. Positive effects on health were observed for patients with both asthma and COPD. And while the improvement was most dramatic for smokers who switched completely to vaping, many of the dual users who cut down substantially on the amount they smoked did experience health improvement. Dr. Polosa also found that smokers with hypertension who switched to e-cigarettes experienced a significant decrease in their blood pressure.

While we can argue about the potential long-term risks associated with vaping, it is simply not the case that e-cigarettes have no credible public health value in real world use. What do you call more than one million smokers quitting using e-cigarettes? If that doesn't have public health value, then I don't know what does. And that is a conservative estimate, since there are an estimated 2.5 million ex-smokers who currently vape. (While some of them may represent ex-smokers who picked up vaping, the vast majority almost certainly are smokers who switched to vaping.)

The New York State Department of Health is also being irresponsible in its direct communications to the public. In a press release issued just 2 days ago, it incorrectly claimed that e-cigarettes are a form of tobacco use. The truth is that e-cigarettes are not a form of tobacco use because they don't actually contain any tobacco. They are no more a form of tobacco use than nicotine replacement therapy. We don't say that using the nicotine patch is a form of tobacco use. Neither is vaping.

The department, in the same press release, claimed that e-cigarette use can be a gateway to nicotine addiction. There is no evidence to support this conclusion. Despite dramatic increases in youth e-cigarette use, the prevalence of nonsmoking youth who have become regular users of e-cigarettes (and thus potentially addicted) is miniscule. Thus, the current evidence is that e-cigarettes actually have a very low potential to serve as a gateway to nicotine addiction.

New York's own data demonstrate that e-cigarettes are not serving as a gateway to smoking. Despite a doubling of e-cigarette use among youth between 2014 and 2016, youth smoking in New York in 2016 reached a historic low. Current smoking among youth in 2016 was only 4.3%.

In fact, while e-cigarette use among youth in New York state rose dramatically from 10.5% in 2014 to 20.6% in 2016, youth smoking plummeted from 7.3% to 4.3%. And if you go back to 2012, when youth e-cigarette use wasn't even measured, the decline in youth smoking is from 11.9% to 4.3%. These data are simply not consistent with the hypothesis that e-cigarette use is a gateway to smoking among youth. If anything, it appears that e-cigarettes may be contributing to the further de-normalization of youth smoking. The emergence of a vaping culture appears to serve as an alternative to the smoking culture, not the other way around.

The rest of the story is that the New York Department of Health is spreading dangerous misinformation and irresponsible medical advice that has the potential to do public health damage. Hopefully, they will correct this misinformation and retract their misguided advice to physicians. They need to do this in order to prevent the unintended effect of their communications, which is to promote smoking by protecting it from competition by vaping products.

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