Moving Past The e-Cigarette Wars: A Perspective From the Tobacco Control Trenches

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There is a war going on. A war that was once contained within the tobacco control community has slowly leaked out into the public sphere. It’s over something small enough to hold in your hand but with the promise of ending generations of death and disease caused by tobacco. It’s an e-cigarette, and the research and policy debates are just beginning to heat up.

Introduced into the US from China in 2007, e-cigarettes are battery-powered devices that simulate cigarette smoking by vaporizing a liquid solution that contains nicotine, flavoring and small amounts of other ingredients. Although the exact chemical make-up of e-cigarettes is variable, a recent systematic review across studies indicates few chemicals that are of any concern with regards to health. In contrast, a cigarette contains about 600 ingredients that create more than 4,000 chemicals when burned, at least 50 of which are known to cause cancer.

It is no surprise then that e-cigarettes—which look and feel like the “real thing”—are gaining in popularity. Approximately 20% of adults have already tried e-cigarettes and, as of 2013, e-cigarettes have become a billion-dollar industry. Sales continue to grow at an exponential rate, and according to the Bloomberg Industries, may pass those of traditional cigarettes by 2047.

But if you thought that their rise would go unfettered, then you have obviously not been following the news.

In the wake of an anticipated decision by the FDA on whether or not to regulate e-cigarettes, and following consideration or implementation of regulations in cities across the country banning e-cigarette use in public places, the debate is intensifying. Tensions among scientists are high, with some arguing that e-cigarettes are the golden path to a reduction in the immense death and disability associated with tobacco, and others seeing them as a path right back to it. Organizations such as the Campaign for Tobacco Free Kids and American Lung Association are prominently asserting that e-cigarettes should be regulated, as the safety has not yet been proven, cessation claims are still unfounded and the marketing is directly targeting kids. On the other hand, tobacco and e-cigarette industries are stepping up their commitment to convince politicians and the media that e-cigarettes are the road to better health, something that regulation will only undermine. All of this is occurring, of course, under the perceptive eye of the media, with publications such as the New York Times , Fox News, Newsday and others racing to cover the debate and offer up their opinions.

Consumers are not taking a back seat to this conversation; e-cigarette and quit smoking forums are ablaze with discussion on the value of e-cigarettes, potential government regulation and the divergent viewpoints of the scientific community. Almost every popular press article published on e-cigarettes is accompanied by a long and heated comment war of consumer e-cigarette advocates pitted against opponents. Even the Hollywood elite are getting in on the action, as e-cigarettes have been featured in the hands of stars like Katherine Heigl, Julia Louis-Dreyfus, Leo DiCaprio, Robert Pattinson, and most recently Kevin Spacey in House of Cards, who satisfyingly declared them as “addiction without the consequences”.

There are big stakes in this game. There is money to be made by the companies that manufacture and sell e-cigarettes, there are constituents to please, there are workers to keep employed, and there is the public’s safety to ensure. Regulation by the FDA has the potential to greatly impact how e-cigarettes are marketed, sold and used in this country. And as the media is so quick to point out, once the decision on regulation is made, someone stands to lose.

But does it really have to be this way?

e-Cigarettes have great potential to reduce the death and disability caused by tobacco in this country. On a one-to-one basis, there is no doubt that e-cigarettes are less harmful than combustible cigarettes. So, if we could convince smokers to throw away their cigarettes and instead use an e-cigarette, wouldn’t we all benefit?

I’ve read the science. I’ve even contributed to the science. I’m well aware that some studies suggest that “dual-use” is a problem–that is, that e-cigarettes are being used in addition to other tobacco products. But let’s break down what may underlie this phenomenon. First, it’s important to note that many studies addressing e-cigarette use really are asking if respondents have “ever” used the product. Yes, that’s right. This means that they could have used the product perhaps just one time. If you consider this, then studies that signal dual-use could merely be indicating that smokers tried e-cigarettes once and weren’t yet satisfied with the technology. Because of the cross-sectional nature of the data, we also don’t know where smokers are in their quitting journey. Dual-use could signify that smokers are trying to make the switch from cigarettes to e-cigarettes and haven’t yet succeeded. While smokers may simply be supplementing their cigarette use with e-cigarettes when they can’t smoke, it is unlikely that many smokers would continue smoking the same amount of cigarettes and just supplement their use with additional e-cigarettes on a regular basis. If this were the case, improving the appeal of e-cigarettes to smokers, e-cigarette cost reductions, increased cigarette taxes and public education could go a long way into moving smokers from dual-use to sole e-cigarette use.

And what about those assertions that e-cigarette companies are marketing to kids?

In two studies I conducted on the advertising tactics of the tobacco and e-cigarette industries (published recently in Tobacco Control and in Nicotine and Tobacco Research), there was some evidence that minors were being exposed to some e-cigarette advertising. We can’t say whether this exposure was intentional, as surely minors are exposed to a lot of advertising that isn’t necessarily targeted to them. Regardless, public health professionals are correct in asserting that we should continue monitoring and restricting the marketing of e-cigarettes to kids. But we shouldn’t restrict the ability of e-cigarette companies to market to adults, especially if their product can help smokers quit a deadly habit.

Admittedly, e-cigarette research is still in its relative infancy, but we don’t have time to wait 5, 10 or 15 years until the longitudinal studies on e-cigarettes are completed. We know enough about the technology to at least conclude that an e-cigarette conveys less harm than a cigarette and may help some smokers quit. It’s time to move on, to focus on how to leverage these benefits to get more smokers off of combustible tobacco products for good.

This war has divided what is usually a united public health front–turning tobacco control scientists normally in partnership against one another. It is the first time in my career that I have heard nervousness from researchers about putting forth data for fear of how it will be received, for fear that science may one day prove them wrong.

It shouldn’t be this way. e-Cigarettes may not be perfect, but if we start focusing the conversation more on how to optimize this technology and use policy and education to drive down combustible tobacco product use, we’d go a long way to reducing the immense death and disability associated with smoking and improving the health of this population and the next.

–Amanda Richardson, PhD MS

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Richardson (2014), Moving Past The e-Cigarette Wars: A Perspective From the Tobacco Control Trenches, accessed: 2014-03-19
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