Treat E-Cigarettes with Extreme Caution and Skepticism to Protect Health
Tobacco is the single leading preventable cause of death. Nothing would save more lives and improve human health as much as eliminating the use of cigarettes. In recent years, the public health community has had notable success in reducing smoking in many countries. Still, tobacco use has soared in China and elsewhere in Asia, and the tobacco industry has trained its sights on the rapidly growing economies and emerging markets in Africa.
Where do electronic cigarettes (e-cigarettes) fit in the fight against the tobacco epidemic? The public health community has itself been divided on this issue, but the evidence shows there is reason for extreme caution about embracing e-cigarettes.
E-cigarettes are a type of electronic nicotine delivery system (ENDS). Typically, they contain varying amounts of nicotine, dissolved in a solvent and often flavored, which is then heated to create a vapor that is inhaled so that it can reach the brain and satisfy the nicotine craving that drives smokers to light up all day. Some also come with a non-nicotine option. Advocates for wider adoption of e-cigarettes see them as a valuable harm reduction device that will decrease the damage caused by smoking tobacco, since e-cigarettes contain fewer of the 7000-plus chemicals that are produced when tobacco is burned and inhaled. Public Health England has taken this position, stating that using e-cigarettes is 95 percent safer than smoking tobacco.
So what’s the problem? Some experts would probably agree that for a regular smoker, an e-cigarette is less harmful than a conventional cigarette and many feel this should be the end of the discussion. However, there are several reasons to be skeptical of the unregulated promotion and use of e-cigarettes.
First, there is just no solid scientific evidence that e-cigarettes are any more successful as smoking cessation devices than conventional forms of nicotine replacement therapy. The most rigorous scientific studies (i.e., randomized controlled trials) don’t find any cessation advantage for e-cigarettes. There are widespread anecdotes suggesting that e-cigarettes helped people quit, but the best data just don’t bear that out. Even if e-cigarettes are less harmful than tobacco, do they simply serve as a way to get a nicotine fix in the places where tobacco can’t be smoked, driving dual-use rather than encouraging cessation? Do they decrease tobacco use enough to really reduce the harm? Such data doesn’t exist yet, but it’s an urgent question.
Second, the production of e-cigarettes is unregulated and the safety is questionable. The solvents in which nicotine is dissolved can decompose when heated and be transformed into toxic compounds such as formaldehyde, while the added flavorings have not been vetted as safe to inhale. Recent studies in animals show that e-cigarette vapor can cause at least some of the same types of lung damage as conventional cigarettes. Is this the nicotine, the flavoring or the solvent, or all three? It’s critical to know.
Third, big tobacco increasingly dominates the e-cigarette industry, as the large cigarette companies have taken over most of the e-cigarette producers. Given that no industry is less deserving of the benefit of the doubt when it comes to protecting the public’s health, this alone should be a cause of great concern. Are e-cigarettes really just a way to addict more of the world’s population to nicotine, which may be safer than tobacco but which is certainly more dangerous than not smoking anything at all? There is ample evidence that this is exactly what the industry is doing.
We should remember that nicotine is one of the world’s most addictive substances, yet it’s easy to buy e-cigarettes that taste like bubble gum, gum drops, or breakfast cereal. This seems a strategy designed to appeal to children, and it is working. Reports from the U.S. CDC and elsewhere indicate that increasing numbers of children have tried e-cigarettes. Getting children started on smoking at a young age has always been a key part of the tobacco industry’s strategy for conventional cigarettes, and it seems that they are using the same playbook for e-cigarettes.
Fourth, it’s possible that Big Tobacco is employing a brilliant diversionary tactic by promoting e-cigarettes. We should really be focusing on strategies that have pushed smoking rates down to historic lows in places like New York City and elsewhere: raising taxes on cigarettes, passing laws that forbid sales to people under the age of 18, banning smoking in public places, and countering the tobacco industry’s sales and promotion efforts with advocacy and education. We shouldn’t be distracted by big tobacco’s profit-making agenda, when we can implement proven measures that definitively have no adverse effects on health.
Would a two-pack-a-day smoker who has failed multiple quit attempts be better off switching completely to e-cigarettes? Probably. Would he or she be better off smoking one pack a day and using e-cigarettes the rest of the time? That’s a harder question to answer. Even low levels of cigarette consumption are proven to cause harm, so the benefit probably would be minimal. Would a teenager who doesn’t smoke at all be doing a good thing by starting to smoke candy-flavored e-cigarettes that trigger a life-long nicotine addiction? Certainly not.
The issue isn’t simple, so the proper public health response to e-cigarettes should be one of extreme caution – until we figure out whether we can use them to reduce harm among existing smokers, while protecting the many – especially youth – whom they have the potential to hurt.
Dr. Neil Schluger is Senior Advisor for Science and Education at Vital Strategies, a global health nonprofit with a legacy of work on tobacco control and limiting the health harms caused by smoking.