Thursday, December 12, 2013

World Health Organization's Medical Advice to Smokers Who Failed to Quit Using Drugs: Public Health Malpractice

Last July, the World Health Organization publicly issued medical advice to smokers wishing to quit: do not use electronic cigarettes.

This remains the current medical advice from the World Health Organization regarding the use of e-cigarettes.

The World Health Organization's statement reads as follows:

"There are no scientifically proven instructions for using ENDS as replacements or to quit smoking. The implied health benefits associated with these claims are unsubstantiated or may be based on inaccurate or misleading information. When ENDS are used as cessations aids, they are intended to deliver nicotine directly to the lungs. ... Until such time as a given ENDS is deemed safe and effective and of acceptable quality by a competent national regulatory body, consumers should be strongly advised not to use any of these products, including electronic cigarettes."

The U.S. Department of Health and Human Services offers the same advice, although not worded quite as strongly: "There haven’t been any scientific studies that prove e-cigs actually help people to quit smoking. ... The bottom line is that we just don’t know enough about e-cigs, so we don’t recommend that you use them. There are other quit aids, with or without nicotine, that have been proven to be safe and effective at helping people quit smoking."

The Rest of the Story

Here's the problem: What is the official advice of the World Health Organization and the Department of Health and Human Services regarding the following patient?

J.B. is a 58 year-old male smoker who has smoked approximately one pack per day for 40 years, starting at age 18. He has tried to quit multiple times using nicotine replacement therapy, but failed. He has tried the nicotine patch six times, nicotine gum twice, and the nicotine inhaler once. He also tried Chantix, but had to discontinue after three days because he was feeling suicidal. His doctor advised him against trying Zyban. He has no history of heart disease and feels reasonably healthy, although he used to be able to jog 3 miles and now can only jog 2 miles before feeling shortness of breath. His blood pressure and cholesterol levels are normal, and there is no family history of heart disease or cancer. He reports that he has two close friends and one family member who recently quit smoking successfully using electronic cigarettes and he has expressed extreme interest in the product. He comes to you for advice on whether to give electronic cigarettes a try.

According to the World Health Organization, their advice for this patient is to try to quit using nicotine replacement therapy, even though he has failed 9 times! They would strongly discourage him from trying electronic cigarettes.

According to the Department of Health and Human Services, their advice for this patient is to try to quit using nicotine replacement therapy, even though he has already failed 9 times! They would discourage him from trying electronic cigarettes.

In my opinion, given the availability of electronic cigarettes and the observed success of these products among many smokers, the advice being given by the WHO and by DHHS is inappropriate. In fact, in my view, it represents public health malpractice.

If a doctor were to give this same advice to J.B., it would be completely inappropriate, and in fact, I think it would represent malpractice. A responsible physician would take into account the fact that this individual has failed to quit 9 times with NRT and would conclude that another trial of NRT is unlikely to be effective. The physician would see that the patient is extremely interested in and motivated by electronic cigarettes and has a support group around him that has used electronic cigarettes and is encouraging him to do the same. Certainly, a trial of electronic cigarettes may very well be warranted in this patient.

You can see from this example exactly why the medical advice being given by the WHO and DHHS represents public health malpractice.  

What makes these examples worse, and what truly makes them constitute malpractice, is that they not only provide bad advice without knowing the complete patient history, but they base that advice on false information.

The WHO claims that electronic cigarettes deliver nicotine "directly to the lungs." There is no evidence that this is true. In fact, electronic cigarettes produce an aerosol, much like nicotine inhalers, and it is likely that the overwhelming majority of the nicotine is absorbed in the upper respiratory tract, never making it down to the lungs. In fact, this is one of the reasons why vaping is not as satisfactory as smoking to many smokers.

The DHHS claims that there "haven’t been any scientific studies that prove e-cigs actually help people to quit smoking." This is also untrue. There are several studies which show that electronic cigarettes are helpful to many people in quitting smoking, although the results may not be as impressive as we would like to see. Nevertheless, a rigorous clinical trial demonstrated that electronic cigarettes are as effective as the nicotine patch. Unless the DHHS is prepared to argue that NRT is ineffective, it should not claim that electronic cigarettes are ineffective. Certainly, more data is needed before we can quantify the effectiveness of electronic cigarettes, but to say that there is no scientific evidence for the effectiveness of these products is just not truthful.

In my opinion, it is malpractice to provide medical advice to a patient without knowing the relevant aspects of that patient's history. Most physicians would agree that a doctor should not give medical advice without knowing the relevant history. But this is exactly what the WHO and DHHS are doing.

They are making blanket recommendations that people do not use electronic cigarettes without knowing the medical histories of these people. Perhaps they have tried to quit multiple times with NRT and have failed. Perhaps they have no interest in trying NRT. Perhaps they have decided that they will not quit unless they can use electronic cigarettes. Perhaps they have decided that electronic cigarettes are their only hope.

For such patients, the blanket advice from the WHO and from DHHS is still: We recommend that you not quit using electronic cigarettes. We recommend that you try NRT again, even though you have no interest in using it and will obviously not try again it given your history.

The central tenet of medicine and public health is "to do no harm." Both the WHO and DHHS are doing harm by disseminating inappropriate medical advice without adequate knowledge of the medical history of the people seeking that advice and based on information that is not factual. This, in my mind, is an example of public health malpractice.

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