HIQA tell it like it is

The HIQA ” Report on the results of the public consultation on the draft health technology assessment (HTA) of smoking cessation interventions” is published. Yes, it’s a hell of a title and it’s a hell of a document. 182 pages not counting the appendices.

It’s available on their website here; HTA of smoking cessation interventions



For those of you wondering who HIQA are,

The Health Information and Quality Authority (HIQA) is an independent authority
established to drive high quality and safe care for people using our health and social
care services in Ireland. HIQA’s role is to develop standards, inspect and review
health and social care services and support informed decisions on how services are

“In January 2016, HIQA commenced a health technology assessment (HTA) of
smoking cessation interventions following a request from the Department of Health
for HIQA to examine the clinical and cost-effectiveness of a range of different
treatments to help people quit smoking. The aim of the HTA is to inform health
policy decisions about potential improvements to the provision of smoking cessation
services within Ireland’s public health service.”

The message the government got!

Tasked with this, they critically examined all the cessation methods, pharmacopeia and self-help, counseling, patches, lozenges, and e-cigarettes. They duly published a draft report and held a public consultation. At the time, the draft report was covered in the media as saying e-cigs work.  They were almost as effective as combination therapy and at half the cost. We all cheered and thought that this evidence would mean that e-cigs would now find a place in the tobacco-free Ireland toolbox. Not that we give a damn about a tobacco-free Ireland, it just means we get less stick for vaping.

So we sent in our submissions and waited for the set of recommendations.

Scratch that, we didn’t exactly inundate them with responses. Though the largest reaction was to e-cigarettes, only 13 of those were from individuals. 13! 48 responses and only 13 from individuals!

35 were from organizations, health bodies, charities, business orgs and such. Which means at best only 12 other people sent in a response!! I would call that bloody exasperating and downright disheartening. Oh well.

Of those  48 responses, most were negative both to e-cigs and also to the treatment with the most actual evidence backed success rate, varenicline in combination with NRT. Remember this was found to be the most cost effective and effective solutions in the draft report. It’s almost as if a large section of the country’s health charities don’t want to see a tobacco-free Ireland at all.

Anyway, what is interesting about this is the fact that in the draft report, HIQA found combination varenicline and NRT as the most cost effective and e-cigs a close second. When the recommendations to the government are published, it turns out their’s not enough evidence for e-cigs and the recommendations are to wait until there is. I suspect the strength of the negative responses had more influence on this than the research data.

Evidence-based ?

A complete synthesis of the available evidence in relation to the long-term health
effects of e-cigarette use is beyond the scope of this HTA. However, the work of
other public health bodies did not indicate that there was sufficient evidence of
harms to exclude e-cigarettes as a smoking cessation intervention in this HTA

This quote, the emphasis is mine, shows that someone in HIQA “gets it” and seems intended to scold the naysayers.

there is a concern that a policy decision for smoking cessation practitioners to
advocate the use of e-cigarettes by those attempting to quit may contribute to
increased e-cigarette use among people who have never smoked. This type of e-
cigarette use may act as a gateway to smoking combustible tobacco. It is difficult to
estimate the relative contribution of promoting e-cigarettes as a smoking cessation
aid to any growth in the use of e-cigarettes among people who have never smoked,
as it is likely to be influenced by a range of other factors, such as marketing of e-
cigarette companies and regulations on the sale of these products. Estimating the
proportion of people who would later switch from e-cigarettes to smoking (but would never have started smoking were it not for having been e-cigarette users) is even more uncertain.

They even access the gateway theory correctly, yet give it sufficient credence to reject recommending e-cigs. Cognitive dissonance?

Now we get to the real reason for the objection to e-cigs,

The underlying issue that connects all of these comments is the impact these
issues will have on the uptake rates of the most effective quitting interventions.

Yes, impact on incumbent players, remember that the draft report ranked e-cigs second in cost effectiveness. Of course one of those incumbent players is lit cigarettes but whatever.

In fairness to HIQA, they did an excellent job of evaluating the evidence, sifting through hundreds of reports, analyzing the data, rejecting reports that lacked credibility and offering the result in an impartial manner. My main fault with it is, it examines the issue through a medical lens. Harm reduction is mentioned and I get the impression HIQA wish harm reduction was part of their remit.

While considerations about harm reduction, including the potential role of e-
cigarettes among the subgroup of smokers who do not want to make a quit
attempt, are beyond the scope of this HTA, the feedback received on this issue
provides a valuable resource for smoking cessation policy-makers to consider as
part of the wider approach to tobacco control in Ireland.

Shame they didn’t force this point more, ahem, forcibly.

Page 31 is someone calling for outdoor bans on smoking, to be expected but infuriating as it has no benefit to anyone other than aesthetic. This is supposed to be about health measures.

Anyway, I’ve spent too much time on this already, it’s an excellent report, carefully worded and well researched. It holds it’s focus on it’s brief; government funded interventions and the cost-benefit assessment of them.

The biggest shame is that lobbying had such influence on the final report over the draft report. It certainly shows that making the effort to respond is important.

The message the public got!

Concerns vaping may act as ‘gateway’ to tobacco cigarettes

That’s the Examiner being used as an example of the kind of spin the report got. Pretty much the same in the Irish Times and RTE online. Here it is being discussed on RTE’s Drivetime;

HIQA report on e-cigerettes

Note the misrepresentation of the subject of the actual report in the title!


I thought it must have been the emphasis given in the press release from HIQA

HIQA press release

Yep, it’s right there. Not surprising as e-cigs drew the biggest response during the consultation period. What is disappointing is how their position moved from the draft report.

“HIQA’s analysis shows that increased uptake of e-cigarettes as an aid to quitting would increase the number of people who successfully quit compared with the existing situation in Ireland and would be cost-effective, provided that the currently available evidence on their effectiveness is confirmed by further studies,”

Again this shows the value of letting them know. Perhaps if hundreds or thousands of the current users of e-cigs had replied to the consultation instead of a paltry 13, we would have had a more positive result.

Lesson to be learned,

Use the opportunities given to tell them your story. No use complaining when it’s all regulated away from you if you made no effort. While this report is now finished, it’s only advisory and goes to the Joint Committee on Health and to the minister for further discussion and decisions. In other words, their’s one last chance to have your say. E-mail, write or personally contact the committee or its members. Tell them your story and emphasize how any move to further restrict e-cig access or use will have a damaging effect on you. Tell them how they helped you, it’s not about having e-cigs included as cessation therapies. It’s about not having e-cigs treated as smoking, taxed as smoking and restricted in availability to smokers.

Contact details here;

Joint Health Committee

And list of the members on this page;

Joint Committee on Health – Membership




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