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Global review on use of e-cigarettes as anti-smoking aid sparks debate in Pakistan

By Shahina Maqbool
October 25, 2020

Islamabad : Even though a belated development, medical professionals and representatives of tobacco control entities in Pakistan have finally broken the silence around whether e-cigarettes (ECs) should be promoted as effective anti-smoking aids for smokers attempting to quit.

The impetus to discuss the use of ECs for smoking cessation—a subject mired in controversy—came from the recently released Cochrane Review which provides “moderate-certainty evidence” that nicotine containing ECs are 70% more effective in supporting smokers to quit as compared to nicotine-free ECs, and even Nicotine Replacement Therapy (NRT). The review includes 50 studies representing 12,430 participants; its objective was to determine the effectiveness of ECs for smoking cessation.

While opinions are greatly divided, the fact that the review has generated a debate on the issue in Pakistan is itself quite encouraging. Even though smoking cessation lowers a person’s risk of getting lung cancer and other Non-Communicable Diseases (NCDs), quitting has never been easy for a vast majority. ‘The News’ spoke to leading cardiologists and anti-tobacco activists in a bid to initiate exchange of views on a subject which, until yesterday, was stiffly resisted as being a tobacco industry ploy.

Consultant cardiac surgeon at Shifa International Hospital (SIH) Prof. Dr. Khalid Rasheed conceded that ECs have, in recent years, become a very popular quit-smoking aid touted to be far less harmful than cigarettes. “The device allows users to inhale nicotine in a vapour rather than smoke; does not burn tobacco; and does not produce tar and carbonmonoxide—two of the most damaging ingredients of tobacco smoke. However, besides nicotine, ECs contain harmful ingredients like ultrafine particles and flovorants that are linked to serious lung injury,” he pointed out.

Commenting on whether nicotine-containing ECs can protect from using cigarettes and increase quit rates, Dr. Khalid referred to a major UK clinical trial published in 2019, which found that people who used ECs to quit smoking were twice on likely to succeed as people who used other nicotine products such as patches or gums. “Remember that you will not get the full benefit from vaping unless you stop smoking cigarettes completely. The fact of the matter is that by vaping, one ends up using a much larger amount of nicotine and becomes more addicted to it.”

Dr. Khalid also quoted Johns Hopkins University studies which have shown that EC users are more prone to the use of normal cigarettes, which is akin to being ‘out of the frying pan into the fire.’ “No matter how it is delivered, nicotine is highly addictive and harmful, and adversely affects brain development,” he stated.

Another consultant cardiologist Dr. Asaad Akbar Khan, also a member of SIH’s cardiology team, said, “Before we start using nicotine-containing ECs as the gold standard therapy for people interested in quitting smoking, we must remember that in addition to the fact that nicotine is very addictive, ECs contain harmful harmful ingredients such as ultrafine particles that can be inhaled deep into the lungs, flavorants such as diacetyl—a chemical linked to serious lung disease—volatile organic compounds, and heavy metals such as nickel, tin, and lead.” He said, the Cochrane Review only points to a signal which needs more diverse data before it can be considered a definitely superior therapy.

Professor of Medicine and Cardiology and former Executive Director of the Rawalpindi Institute of Cardiology Azhar M. Kayani, said, there are no conclusive studies on the effects of using ECs to help smokers with long-term abstinence. “E-cigarettes with nicotine are as harmful to the body as smoking tobacco,” he stated. Dr. Azhar said, ECs without nicotine will only help a handful of individuals who occasionally smoke on a recreational basis and are not addicted to the nicotine drug. “It will allow them to continue the habit on a social basis without damaging their body. However, most smokers have nicotine drug dependency and e-cigarettes without nicotine will not have any impact on reducing their need for the drug,” he stated. Dr. Azhar termed total abstinence as the only way to alleviate the adverse impact of smoking.

Nadeem Iqbal from TheNetwork for Consumer Protection urged the government to come up with an evidence-based quit smoking programme with inputs from growing international evidence in favour of nicotine-based ECs. He said, the introduction of NRT in the Essential Drug List only two years ago has had no impact so far. “We are faced with the daunting task of extending cessation facilities to around 14.7 million smokers. With youth in particular picking up e-cigarettes, the health authorities must develop a cessation policy with the use of safer products to save 160,000 lives being unnecessarily lost to combustible tobacco every year,” he added.

Arshad Ali Syed from the Pakistan Alliance for Nicotine Harm Reduction said, credible research is constantly highlighting the critical role that tobacco harm reduction can play in bringing down combustible smoking prevalence, especially in countries like Pakistan. He also underlined the need to listen to smokers in order to determine what kind of help they need to quit smoking.

Representing the viewpoint of The Union as its technical advisor for tobacco control in Pakistan, Khurram Hashmi termed this new phenomenon as the tobacco industry’s tactic to lure in youth for their transition to tobacco addictions. “The tobacco industry is using these trendy products to target youth. These products are nothing but nicotine delivery devices that pose serious health issues. It is just nother innovative distraction from the exemplary tobacco control work going on in Pakistan,” he pointed out.

Mazhar Arif, executive director of the Society for Alternative Media and Research (SAMAR) and focal person of the Coalition for Tobacco Control-Pakistan also rejected the Cochrane Review’s claim that ECs with nicotine increase quit rates compared to ECs without nicotine and compared to NRT As pointed out by authors of the Cochrane Review, Mazhar also stressed that more reliable evidence is required to be confident about the effects of ECs. He added, since ECs are unaffordable for a majority of the smokers in Pakistan, more cessation clinics should be established to provide quitting services.