While most discussion of e-cigarettes among health authorities has concentrated on the product itself, its potential toxicity and use of e-cigarettes to help people quit smoking, the e- cigarette companies have been rapidly expanding using aggressive marketing messages similar to those used to promote cigarettes in the 1950s and 1960s. Moreover, e-cigarette advertising is on television and radio in many countries that have long-banned similar advertising for cigarettes and other tobacco products. While it may be reasonable to assume that if existing smokers switched completely from conventional cigarettes (with no other changes in use patterns) there would be a lower disease burden caused by nicotine addiction, the evidence available at this time (while limited) points to high levels of dual use of e-cigarettes with conventional cigarettes, little benefit for cessation (either on a population basis or compared to currently regulated nicotine replacement therapy) and rapidly increasing youth initiation with e-cigarettes. Although, some cite a desire to quit smoking by using the e-cigarette, other common reasons respondents give for using the products are to circumvent smokefree laws and to cut down, which may reinforce dual use patterns.
It is unclear what will be the trajectory of the dual use pattern among adults or children, but any uptake in children is very concerning. Nicotine is a highly addictive substance with negative effects on animal and human brain development, which is still ongoing in adolescence.(Dwyer et al., 2008, Liao et al., 2012, Lichtensteiger et al., 1988, Longo et al., 2013) Evidence from published studies examining dual use of smokeless tobacco, snus and conventional cigarettes among youth and adults shows a progression to cigarette smoking and difficulty with quitting among adolescent smokeless tobacco users.(Galanti et al., 2008, Post et al., 2010) Concerns that e-cigarettes could play a similar role in increasing conventional cigarette use are warranted. Furthermore, high rates of dual use may result in greater total public health burden and possibly increased individual risk if a smoker maintains an even low-level tobacco cigarette addiction for many years instead of quitting.
E-cigarette devices and their components should be evaluated for risks posed to consumers by consumer product safety regulatory authorities and consumers should be appropriately warned about risks and proper handling. Although the data are limited, it is clear that e-cigarette aerosol is not “harmless water vapor” as is frequently claimed and can be a source of air pollution. Article 8 of the FCTC focuses on smoke-free policies to afford protections for the public and all workers to breathe clean air. When evaluating the risks of exposure to e-cigarette aerosol, the standard of comparison should not be whether the vapor is better than the toxic chemical mixture in tobacco cigarette smoke (which is already prohibited), it should be whether the product’s emissions introduce toxins into clean air, and how they affect existing public health protections. In contrast to the paucity of research on e-cigarettes, there is an extensive scientific literature showing that smokefree policies protect nonsmokers from exposure to toxins and encourage smoking cessation.(U.S. Department of Health and Human Services, 2006) One-hundred percent smoke-free policies have about twice the effect on consumption and smoking prevalence than policies with exceptions or partial coverage.(Fichtenberg and Glantz, 2002) Exceptions for e-cigarettes may similarly decrease the effects of smoke-free policies on smoking cessation, and as noted in the FCTC Conference of the Parties report, use of the products in smokefree environments may also decrease enforcement of Article 13 as e-cigarettes act as cigarette-mimicking products. Introducing e-cigarettes into clean air environments may result in population harm if use of the product reinforces the act of smoking as socially acceptable, and/or if use undermines the effects of smoke-free policies on smoking cessation. Strong smoke-free policies are an integral part of the recognized and proven comprehensive global tobacco control policies.