E-cigarettes: cessation tool or a harmful product? A false dichotomy

In June this year, WHO came out strongly against e-cigarettes, stating that they are harmful to health. This position has been criticised as undermining efforts to reduce combustible smoking and its related harms. 

However, e-cigarettes also contain nicotine that makes them addictive as well as chemicals whose long-term impact on health is still relatively unknown. They cannot, therefore, be dismissed as harmless – even if the nature of those harms may be different from those of conventional cigarettes. 

There are also studies now suggesting that e-cigarette use by non-smoking young adults can lead to nicotine dependence and the later smoking of conventional tobacco products. Recent figures from Canada show not only a 74% increase in vaping among 16-19 year-olds from 2017 to 2018 but also a rise in the prevalence of cigarette smoking by 45% in the same time period, reversing two decades of decline. The US has also seen a dramatic rise in e-cigarette consumption, with one in three high school students admitting to vaping in 2019. 

Therefore, there are justified concerns among public health advocates that e-cigarettes are serving as a gateway to combustible smoking. Furthermore, there appears to be a growing number of young adults who may never have smoked (well aware of the risks thanks to decades of information) and who are now using a nicotine-based product that can be harmful to their health but is not perceived as such due to the mixed messages they receive particularly through marketing efforts by the tobacco industry.

In many countries, current legislation for e-cigarettes allows the tobacco industry to aggressively target young people with misleading information and ensure that the next generation will use its products. 

It is unfortunate that there are divergent views in the tobacco control field between those who promote e-cigarettes as cessation tools and those organisations that view them as harmful tobacco products. These divisions only serve the interests of the tobacco industry. The industry is also using tobacco control language to further its own commercial interests, positioning themselves as part of the solution and using false public health arguments to lobby policymakers.

 The scientific evidence regarding the effectiveness of e-cigarettes as a smoking cessation aid is still being debated, with the potential for e-cigarettes to play a role in smoking cessation at a population level currently unclear. However, if evidence does point to the effectiveness of e-cigarettes as a cessation tool for smokers then they should be used as such and not as recreational products, as is now the case.

A key question we need to address is, how do we safely make e-cigarettes available for those who are dependent on smoking without this being a green light for all and create potential downstream issues with continued recreational use? We do not yet know the long-term harms of vaping and research is vital to providing this information. Why should we run the risk of repeating the errors we made with conventional tobacco regulation? The current tobacco epidemic has caused over 100 million premature deaths in the last century and still contributes to more than eight million deaths a year. 

Even if adopting a position against the strict regulation of e-cigarettes is driven by a real desire to reduce the burden of smoking-related diseases, there is a danger that the message about the relative harms of e-cigarettes is interpreted as “vaping is safe(r)”, and – as we have seen – encourages people to engage in a harmful activity when they may not otherwise have done so. 

In fact, I would argue that, to avoid mixed messages and playing into the hands of the tobacco industry, those who see e-cigarettes as means to reduce the harms of combustible smoking should be strong supporters of the recent decision by Australian authorities to require a prescription for e-cigarettes that contain nicotine; this would be delivered only after other methods to quit or reduce smoking had tried and failed. 

Ultimately, presenting e-cigarettes as cessations tools should not prevent supporting their strict regulation. This should not be an ‘either/or’.

Until we know more, e-cigarettes should be considered as tobacco products under the Framework Convention for Tobacco Control. Let us err on the side of caution and potentially adapt regulation as the science becomes clearer, rather than be forced to play catch-up when the market is too big and the consequences too severe.