This past summer, the Atlanta suburb of Roswell, Georgia, banned use of e-cigarettes and vapor pens in public parks. Officials enacted the restriction not because of rampant use of the devices in the city but, as mayor Jere Wood said, to “get ahead of the curve. Smokeless device use is soaring. To fulfill demand, vapor shops are popping up all over.
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Are electronic cigarettes (e-cigarettes) a relatively harmless substitute for cigarettes? Or are they a Trojan horse leading to nicotine addiction and ultimately chronic smoking? Many researchers believe the latter. E-cigarettes are battery-powered devices that deliver aerosolized nicotine and kid-friendly flavored additives, such as chocolate mint, piña colada, atomic fireball candy, and even gummy bears. Designed to mimic the look and habit of smoking, the devices are marketed as a relatively benign alternative to smoking, without the tar, carbon monoxide, and other harmful ingredients adversely affecting the heart and respiratory system. “Vaping,” the term for using e-cigarettes, emits only a cloud of vapor—not secondhand smoke.
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Last year was an important year in the field of public health. In 2014, West Africa, particularly Sierra Leone, Liberia, and Guinea, experienced the worst outbreak of the Ebola virus in history, and with devastating effects. Debates around e-cigarettes and vaping became central, as more research was published about their health implications. Conversations surrounding nutrition and the spread of disease through travel and migration continued in the media and among experts.
We’ve chosen a selection of articles that discuss public health issues that arose in 2014, their effects on the present and implications for the future.
Header image: US specialist helping Afghan nomads by Sfc. Larry Johns (US Army). Public domain via Wikimedia Commons.
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Oxford Dictionaries has selected vape as Word of the Year 2014, so we asked several experts to comment on the growth of electronic cigarettes and the vaping phenomenon.
Vaping is the term for using an electronic cigarette (e-cigarette). Since e-cigarettes involve inhaling vapour rather than smoke, it is distinct from smoking. The vapour looks a somewhat like cigarette smoke but dissipates much more quickly and has very little odour since it mostly consist of water droplets.
E-cigarettes started to become popular around 2010 and it is estimated they are currently being used by more than 2 million people in the United Kingdom and more than 5 million in the United States. Their sale is banned in many countries, including Australia and Canada, although surveys show that use in these is widespread since they can easily be obtained via the Internet.
E-cigarettes are devices in which a battery-powered heating element vaporises an ‘e-liquid’ usually containing propylene glycol or glycerol, nicotine, and flavourings. They are designed to provide much of the experience of smoking but with much lower risk, less annoyance to bystanders, and usually much more cheaply. Because they do not involve burning of tobacco, the concentrations of toxins in the vapour are typically a tiny fraction of those in cigarette smoke. The precise risk from using them is not known, but based on the vapour constituents it would be expected to be between 1% and 5% that of smoking.
Data on e-cigarette use are not available for most countries. By far the most complete data come from England where the ‘Smoking Toolkit Study’ (STS) collects data on usage from nationally representative samples of adults every month enabling this to be tracked closely over time. This study was established to track ‘key performance indicators’ relating to smoking and smoking cessation and has been going since 2007. Action on Smoking and Health also conduct large national surveys of adults and young people each year. Large scale surveys are also being conducted in the United States and some other countries. The data show that most people use e-cigarettes in an effort to protect their health either by stopping smoking altogether or cutting down. Despite misleading claims by some anti- e-cigarette advocates, use by never-smokers and long-term ex-smokers is extremely rare in the UK and US at present, and in England its prevalence in never-smokers and long-term ex-smokers is similar to the use of ‘licensed nicotine products’ (LNPs) such as nicotine patches, gum, or lozenges.
E-cigarettes come in many different forms. In England, the most commonly used ones at present are known as ‘cigalikes’ because they look something like a cigarette and often have a tip that glows when the user takes a puff. Becoming more popular are devices that involve a refillable ‘tank’. There are also more sophisticated ‘mod’ systems which are highly customised. These are often the choice of aficionados.
Most e-cigarette users probably obtain less nicotine from these devices than people typically do from cigarettes, but experienced vapers using tank systems or mods can obtain at least as much nicotine from their devices as do smokers.
When used in a quit attempt, on average e-cigarettes seem to improve the chances of successful quitting by about 50%, similar to licensed nicotine products when used as directed. The main difference appears to be that these devices are much more popular, and they seem to be effective when people use them without any support from a health professional. Currently the evidence still indicates that use of the drug varenicline or a licensed nicotine product with specialist behavioural support provides the best chance of quitting for those smokers who are willing to use this support and where such support is available.
When used for cutting down, daily (but not non-daily) use of e-cigarettes seems to be associated with a modest reduction in cigarette consumption on average. Use of licensed nicotine products for cutting down has been found to be associated with an increased likelihood of later smoking cessation. This has not yet been demonstrated for e-cigarettes, although smokers who use e-cigarettes daily do try to quit smoking more often than those who are not ‘dual users’.
Despite claims from some anti- e-cigarette advocates, in England and the United States, e-cigarettes are currently not acting as a ‘gateway’ to smoking in adolescents or ‘renormalising’ smoking. Youth and adult smoking have continued to decline steadily as e-cigarette use has grown and in England adult smoking cessation rates are somewhat higher than they were before e-cigarettes started to become popular. E-cigarette use in indoor public areas has not led to any increase in smoking in these areas in the UK and compliance with smoke-free legislation remains extremely high.
Some e-cigarette advertising seeks to glamorise vaping and in some countries appears to blur the boundaries between smoking and vaping. This has led to concern that it might make vaping attractive to non-smokers and countries such as the UK have regulated to prevent this.
There is some controversy over vaping. A number of high-profile public health advocates have engaged in what appears to be a propaganda campaign against them, creating an impression in the public consciousness that they are more dangerous than they are and that they are undermining tobacco control efforts when the evidence does not support this. It is reasonable to be concerned about what may happen in the future with tobacco companies dominating the e-cigarette market and being incentivised to maximise tobacco sales, but much of the anti- e-cigarette propaganda appears to be motivated more by a puritanical ethic than a dispassionate assessment of the evidence. Maximising the public heath opportunity presented by e-cigarettes, while minimising the potential threat, requires collecting good data, using this information to construct an appropriate regulatory strategy, and monitoring the situation closely to adjust the strategy as required. England appears to be leading the way in this approach designed to encourage smokers to use e-cigarettes to stop smoking, while not undermining use of potentially more effective quitting methods, and preventing e-cigarettes becoming a gateway into smoking. The Smoking Toolkit Study, the ASH surveys, and other research will continue to provide essential information needed to inform this strategy.
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Oxford Dictionaries has selected vape as Word of the Year 2014, so we asked several experts to comment on the growth of electronic cigarettes and the vaping phenomenon.
A new report from the US Centers of Disease Control and Prevention shows that use of e-cigarettes among high schools students has tripled in two years. The finding raises the question is vaping—the use of tobacco-free electronic cigarettes—an important tool for helping smokers quit or a ploy by Big Tobacco to addict another generation of young people to nicotine? Public health experts are poring over the modest evidence on the health consequences of e-cigarettes to find guidance for policy.
What is clear is that vaping—inhaling and exhaling vaporized nicotine liquid produced by an electronic cigarette—is on the rise not only in the United States but elsewhere. In the United Kingdom, the percent of current smokers had ever tried electronic cigarettes rose from 8.2 in 2010 to 50.6 in 2014.
Big Tobacco has jumped into the e-cigarette business with gusto. By the end of 2013, British American Tobacco, Lorillard, Philip Morris International and Reynolds—key players in the multinational tobacco business—had each bought e-cigarettes companies. While e-cigarettes still constitute a fraction of the tobacco business, their market share has grown rapidly. Retail sales value of e-cigarettes worldwide for 2013 was $2.5 billion and Wells Fargo estimates sales will top $10 billion by 2017.
Supporters of e-cigarettes argue that by satisfying the craving for nicotine these devices can wean smokers from tobacco, reducing the harm from inhaling more than 5,000 chemicals—many of them carcinogenic. Some studies have found that e-cigarettes were modestly effective at helping tobacco smokers to quit. Proponents believe that some tobacco use is inevitable for the foreseeable future so making e-cigarettes available helps reduce the world’s main cause of premature death. They compare e-cigarettes to offering injecting drug users free clean needles, a policy demonstrated to reduce HIV transmission.
Critics reject these arguments. They point to evidence that vaping exposes users to dangerous toxics, including cancer-causing formaldehyde. Of greatest concern, opponents fear that vaping will addict new users to nicotine, serving as a gateway to tobacco use. Some preliminary evidence supports this view. They also worry that e-cigarettes will re-glamorize smoking, undermining the changing social norms that have led to sharp declines in tobacco use.
The inconclusive evidence raises some basic questions. How do we make policy decisions in the face of uncertainty? In setting e-cigarette policy, what are appropriate roles for the market and government? Finally, in a political system where corporate interests have shown a growing capacity to manipulate the rules to achieve their goals, how can the public interest be best protected?
Over the past century, two warring principles have guided policy on consumer rights. The first, caveat emptor, let the buyer beware, says consumers have the obligation to find out what they can about the products they choose to consume. The more recent precautionary principle argues instead that producers should introduce only goods that are proved safe. For e-cigarettes, this would put the onus on manufacturers to demonstrate in advance of widespread marketing that the alleged benefits of vaping outweigh its potential costs. Few researchers believe that such evidence now exists.
The history of Big Tobacco suggest that no industry is less qualified to set public health policy than the corporations that are buying up e-cigarette companies. In her 2006 decision in the United States racketeering trial against the tobacco industry, Judge Gladys Kessler wrote that the tobacco industry “survives, and profits from selling a highly addictive product which causes diseases that lead to … an immeasurable amount of human suffering and economic loss, and a profound burden on our national health care system. Defendants have known many of these facts for at least 50 years or more. Despite that knowledge, they have consistently, repeatedly and with enormous skill and sophistication, denied these facts to the public, the Government, and to the public health community.”
Already the industry’s e-cigarette practices raise concerns. For example, companies have marketed products in flavors like cherry, vanilla, and cookies and cream milkshake. Their advertising has used the same sexual and risk-taking imagery employed to market tobacco to young people. Significantly, manufacturers decided not to promote their products primarily as smoking cessation devices, an approach that would have emphasized public health benefits, but instead as a glamorous, sophisticated new product. This strategy increases the likelihood that the product will create new generations of nicotine addicts rather than help smokers to quit.
Leaving e-cigarette policy in the hands of industry invites Big Tobacco to continue its deceptive practices and use its political resources to undermine public policy. The 2009 Family Smoking Prevention and Tobacco Control Act gave the US Food and Drug Administration the authority to regulate tobacco. In 2014, the FDA proposed new rules to regulate e-cigarettes. These rules would set the minimum age of 18 to use e-cigarettes, prohibit most sales in vending machines, mandate warning labels, and ban free samples. As these rules work their way through the system, advocates have suggested the need for additional rules including a ban on flavored e-cigarettes, limits on marketing, and strict oversight of the truthfulness of health claims.
Lax public health protection from lethal but legal products such as tobacco, foods high in sugar and fat, alcohol, firearms, and automobiles has produced a growing burden of premature deaths and preventable injuries and illnesses. Around the world, chronic diseases and injuries are now the main killers and impose the highest costs on health systems and tax payers. Allowing Big Tobacco to use e-cigarettes to write a new chapter in this sorry history would be a step in the wrong direction.
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