The German Society of Pneumology and Respiratory Medicine (DGP) published an ad hoc statement in early November 2020, once again opposing the use of tobacco heaters and e-cigarettes as alternatives to conventional cigarettes. The reason for this positioning is several works that suggest exactly this. The fronts between supporters and opponents seem to have hardened.
“The fact that the tobacco industry, of all people, which has caused damage over many decades and earned a lot of money with it, is now selling itself as a health-promoting institution with the e-cigarette, I just don’t buy it.” Prof. Dr. Wulf Pankow, representative of the DGP in the Aktionsbündnis Nichtrauchen e.V. (Non-Smoking Action Alliance) and, before his retirement last year, chief physician in the Department of Pneumology at the Vivantes Clinic in Berlin-Neukölln (D), takes an extremely critical view of the developments of recent years in the field of tobacco alternatives. At the center of the criticism is the propagation of e-cigarettes and tobacco heaters as successful means of smoking cessation, also and especially against the background of a lack of long-term studies.
Prof. Pankow, the DGP has published an ad hoc statement on tobacco cessation using e-cigarettes – why now?
Prof. Dr. med. Wulf Pankow:
In colleague circles there is a faction, even if it is small, that propagates the e-cigarette for tobacco cessation and also represents this position very strongly in the press. However, we as a society take a completely different view on this, and due to the lobbying for e-cigarettes, in which the industry is certainly also involved, we found it appropriate and necessary to once again take a clear position on this issue.
The proponents refer to certain studies [2–4], whereas you again cite other studies [5,6] – what exactly are your arguments against the e-cigarette?
First of all, the health risks of e-cigarettes have not been sufficiently researched so far; on the contrary, there is increasing evidence that they can also cause health problems. This starts with indications of carcinogenicity, i.e. cancer-promoting properties, through to lung and vessel-damaging properties, and the long-term health effects are completely unknown. Secondly, we fear, especially in the youth sector, that a new group of buyers will be made addicted to nicotine. While e-cigarettes are advertised as being less harmful to the health of dependent smokers, the whole strategy is aimed at attracting new groups of buyers to e-cigarettes. We know that nicotine is an extremely addictive substance, and when someone turns to e-cigarettes – especially young people – it stands to reason that they will later switch to tobacco. The third point is that we are not convinced that the e-cigarette is better in smoking cessation than what we have well established already in the quiver. So in addition to behavioral therapy nicotine replacement products and also medications. We believe one should stick with what is well researched and where we know the risks and effects, and not switch to a drug that continues to perpetuate nicotine addiction and leaves health risks in the unknown.
That’s very general, but there are different forms: E-cigarettes with and without nicotine, vaporizers, tobacco heaters, also depending on the respective manufacturer – do you not make any distinctions there?
First, we see it in general. As for nicotine addiction, of course the e-cigarettes with nicotine are addictive, so that adds to it. But the other substances that are inhaled are not necessarily harmless either. There are substances that also have potentially harmful effects on health, e.g. formaldehyde, a carcinogen, acrolein, which irritates mucous membranes, acetaldehyde and carbonyl compounds, which are suspected of being carcinogenic, multiple flavorings that are added and whose effect is often not even known, and finally, in the steam that is inhaled, fine dust and metal components that are released by the heating coil, lead, chromium, nickel, etc. So there are a lot of substances that one would not like to see permanently in the lungs. It is always said that this is theater mist and otherwise harmless and is also ingested as a food additive – but it is just not metabolized under high temperatures and permanently inhaled into the lungs. That’s a difference, and there you don’t know the long-term effects.
In your statement, you also call for greater efforts to prevent and treat tobacco addiction. How do you think this should be designed?
Especially with young people, money plays a big role, we know that from tobacco. Money is the strongest inhibitory tool to prevent youth from smoking. That’s where we would like to see higher taxation, both of the cigarette itself and of the e-cigarette. This is also currently being discussed and voted on in Germany; there is an approach from the Ministry of Finance on the issue. And we would consider e-cigarettes to be subject to health protection just as tobacco cigarettes are. The problem with e-cigarettes is: Unlike other drugs, it is not subject to drug safety regulations. It is freely available on the market and therefore it is also difficult to control which substances are contained in the e-cigarette. That’s what distinguishes e-cigarettes from medications, and that’s really a problem.
Prevantion in adolescents is one thing, another is adults who spend years trying in vain to get off tobacco. Possibly pre-diseased patients with cardiovascular problems or COPD who have already been through all nicotine replacement medications and still can’t quit – or maybe don’t want to. Can you not follow doctors who say with this clientele, e-cigarette are not healthy, but at least less bad?
My argument is, first, that surely no one can quantify how much less bad means. There are approximate calculations that e-cigarettes are 95% less bad compared to traditional cigarettes. However, it is important to know that this 95% results from a panel of a dozen experts who were asked how they estimate the danger, and the mean of this estimate was 95%. However, there is no scientific basis for such a quantification. Then it is sometimes argued that there are toxicological studies that show that certain substances are contained less than in tobacco. But even from such numbers you cannot extrapolate to an effect in the organism, that does not work. Therefore, we say, you can not offer as an alternative a product whose harmful effect on health is assumed, but no one knows how much less harmful it is compared to the cigarette. In addition, most smokers who switch to e-cigarettes (60-80%) still continue to use tobacco. The Federal Ministry of Health has also taken a position in this direction, stating that it is not yet possible to say whether e-cigarettes can be an aid to quitting.
But that still doesn’t answer the previous question – how do you respond to colleagues who have severely dependent smokers and say that the strict rejection of the new products misses the practical reality?
I understand the frustration of many physicians, because weaning smokers is an extraordinarily laborious business and as a pulmonologist I can also understand that one despairs a little bit. The good advice of a doctor is helpful, but only for a minority of smokers. One’s experience in practice is that you reach so few, even if it’s maybe 5 or 6%, that you get the impression that it’s of no use at all. Then you just grasp at straws and say ok, if they like to smoke e-cigarettes, let them, it’s probably less dangerous. The main thing is to get them away from tobacco. But we think that falls short, because you also want to get them away from nicotine addiction, and you have to put more effort into that. Tobacco cessation in Germany is simply not well developed. We don’t have a good network of care in the area, so that would be another issue that needs to be worked on urgently. Other countries are much further along in this respect. In England, for example, there are tobacco cessation clinics, where primary care physicians know where to refer patients for tobacco cessation. In our country, there are also contact points, but they are so scattered that it is not really manageable for many physicians on a daily basis.
What would have to happen on the part of both manufacturers and researchers for you to accept an e-cigarette or vaporizer as an alternative to the classic cigarette?
So I would have a basic objection to inhaling nicotine because it usually leads to a permanent addiction. This is a problem that no manufacturer will be able to avoid. I can’t imagine this being modifiable. And beyond that, I would at least require that the health effects be documented over the long term before it can be said that it is a safe product. One would have to present health studies in which a cohort is followed over a period of, say, 10 years and from which one can read the health risks. Such studies do not yet exist, but the e-cigarette has not been on the market long enough for that. But the controversy at that point is sure to continue. And it’s also a bit annoying to always have to deal with e-cigarettes, because I already said: Actually, we have quite a good set of tools for tobacco cessation.
The interview was conducted by Jens Dehn
Literature:
- Tobacco cessation with e-cigarette? An ad hoc statement of the German Society of Pneumology and Respiratory Medicine (DGP), Nov. 2, 2020; https://pneumologie.de/fileadmin/user_upload/Aktuelles/2020-11-02_DGP_Stellungnahme_Tabakentwoehnung_mit_E-Zigarette.pdf.
- Stöver H, et al: New directions for smoking control: tobacco use & harm reduction (“Tobacco Harm Reduction”) 2020; www.frankfurt-university.de/fileadmin/standard/Hochschule/Fachbereich_4/Forschung/ISFF/Veranstaltungen/Webinar_E-Zigaretten_2020/Positionspapier_E-Zigarette_final_12102020.pdf.
- Herring T: E-cigarettes – toxicological fiasco or better than no smoking? Internist 2020; 61: 634-643.
- Hartmann-Boyce J, et al: Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews 2020; 10: CD010216; doi: 10.1002/14651858.CD010216.pub4.
- Pfeifer M: E-cigarettes – risky for health and not recommended for smoking cessation! In-ternist 2020; 61: 1106-1108.
- Kalkhoran S, Glantz SA: E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis 2020; doi: 10.1016/S2213-2600(15)00521-4.
InFo PNEUMOLOGY & ALLERGOLOGY 2020; 2(4): 34-35.
