Electronic cigarettes: the future or the end of smoking?

 

The battle fought on the regulation of electronic cigarettes, i.e. recreational devices that deliver vaporized nicotine without combusting tobacco, epitomizes the philosophical divide over health policy today. Although initial scientific studies suggest that e-cigarettes are safer than conventional tobacco products, the health and anti-smoking communities seems split over the issue. As summed up by Michael Siegel, one of the few anti-smokers in favor of e-cigarettes, ‘the anti-smoking movement's ideology - which is guided by an abstinence only type of philosophy - just doesn't have room for a product that looks and acts like a cigarette but happens to be orders of magnitude safer’. As a result an increasing number of countries across the world are banning e-cigarettes. It is against this backdrop that the UK government, notably the Cabinet Office’s Behavioral Insight Team, better known as Nudge Unit, surprised the health community by coming out in favor of e-cigarettes.

 

 

Alternatives to tobacco smoking exist since cigarette consumption came under the scrutiny of scientists back in the 1960s. The most promising, yet most controversial, is the electronic cigarette, which obtained patent protection in 1963, in the United States of America, as a device aimed at providing ‘a safe and harmless method of smoking by replacing burning tobacco and paper with heated, moist, flavored air...’. Amid the high social acceptance benefited by tobacco throughout the last decades, this device never reached manufacturing and it took almost 50 years before a Chinese pharmacist, Hon Lik, invented the modern e-cigarette in 2003. Today an e-cigarette may be defined as an electrical device that simulates the act of tobacco smoking by producing an inhaled mist bearing the physical sensation, appearance, and often the flavor and nicotine content of inhaled tobacco smoke.

 

 

Since their first appearance e-cigarettes have sparked controversy not only among scientists, who still research on their health effects, but also within the health and tobacco control communities. At a time in which several studies regarding the long-term health effects of nicotine vapor, both inhaled directly and second hand, are currently in progress, an increasing number of governments across the world, supported by the anti-smoking community, are trying to stop the sale of e-cigarettes by either banning them or treating them as drug delivery devices in order to control their placing on the market. 

 

 

Behind such a prohibitionist stance lies the concern that e-cigarettes may not only reduce the incentive for people to quit nicotine but could also return cigarettes the old allure of smoking, thus attracting young people and non smokers to become nicotine addicts. Besides these concerns, an increasing number of actors – not only anti-smoking groups – express scientific doubts about the health effects of these nicotine devices. Yet, no agency has been able to present evidence that these devices may actually cause harm. Rather, most scientific studies seem to suggest that these devices are safer than conventional cigarettes.

 

Facing such an uncertain regulatory environment, manufacturers of e-cigarettes – which are typically small or medium companies, independent from tobacco companies – don’t receive incentives to further develop this technology or invest into new smokeless devices. This is particularly true if one considers that as soon as a manufacturer makes a health claim in relation to e-cigarettes (‘it does not endanger your health’) then such a product automatically becomes a drug or a medical device, and as such it requires a market authorization and tight controls. It is therefore not surprising that, besides Australia, Canada, Brazil, Singapore and Thailand where e-cigarettes are expressly prohibited) – these devices tend not to carry health claims and, as a result, are freely sold. This is clearly the case for most EU countries where the legal status of e-cigarettes and other smokeless products is – to say the least – a significant source of uncertainty, as recently discussed here. E-cigarettes find themselves in a similar legal limbo in the US where the FDA intends to make them undergo scientific vetting before they could be sold in the United States. The FDA regulates smoking-cessation devices, such as patches, so e-cigarette manufacturers are careful to market their devices only as substitutes for cigarettes, not quitting aides. FDA did not appeal the decision by the U.S. Court of Appeals for the D.C. Circuit in Sottera, Inc. v. Food & Drug Administration, holding that e-cigarettes and other nicotine-containing products are not drugs or devices unless they are marketed for therapeutic purposes, but that other nicotine-containing products can be regulated as “tobacco products” under the Federal Food, Drug, and Cosmetic Act.

 

 

 

What makes the prohibitionist stance against e-cigarettes even more doubtful today is the role played by the pharmaceutical industry, which produces the most commercially successful alternative to tobacco smoking (nicotine replacements), in questioning the health effects of the electronic devices. Yet, the only government in the world that seems unimpressed by the e-cigarettes bashing campaign led by the tobacco control community as well as Big Pharma is the UK government. The Cabinet Office’s Behavioral Insight Team recently advised the UK government to encourage the use of new products that deliver nicotine to people’s lungs without harmful toxins and carcinogens in tobacco smoke. In its annual update 2010-11, the Behavioral Insight Team suggests to ‘explore new products for people addicted to nicotine – products that deliver nicotine quickly in a fine vapour instead of as harmful smoke could prove an effective substitute for ‘conventional smoking’. The same report also recommends ‘getting the regulatory framework for these products right, to encourage new products, which smokers can use as safer nicotine alternatives, to be made available in the UK’. The Unit reaches this conclusion by reminding that  ‘A tenet of behaviour change is that it is much easier to substitute a similar behaviour than to extinguish an entrenched habit (an example was the rapid switch from leaded to unleaded fuel). If more alternative and safe nicotine products can be developed which are attractive enough to substitute people away from traditional cigarettes, they could have the potential to save tens of thousands of lives a year’. The language used by the report is rather broad so as to encompass all safe alternatives to tobacco smoking. This is an important caveat: the report – contrary to mainstream media coverage – should probably not to be interpreted as an unconditional endorsement of the actual electronic cigarettes.

 

 

In the meantime, as reported here and here, the EU is revising its Tobacco Products Directive and it is considering whether to extend its scope of application to e-cigarettes (which are defined as ‘electronic nicotine delivery system’) as well as to some smokeless products, such as herbal cigarettes and snus. The latter product is prohibited within the EU with the notable exception of Sweden where it is traditionally manufactured and consumed. Although the European Commission recognizes that ‘an individual substitution of smoking by the use of smokeless tobacco products would probably decrease the incidence of some tobacco-related diseases’ and act as a ‘way to quit smoking’, it also held that ‘at this moment there is not enough scientific evidence available on the efficacy’ of these instruments, snus in particular, as quitting aids. 

 

 

While more and more countries consider banning electronic cigarettes, there is a clear need to produce more independent scientific research on their health effects. For the time being, the criticisms formulated against e-cigarettes seem more ideological than science-based and clash with equally strong arguments for the value of e-cigarettes as a harm reduction strategy. In particular, the stance adopted by mainstream health and tobacco control communities against these devices has more to do with an ideological rejection of the ‘harm reduction approach’ (which has instead been embraced in alcohol) than with scientific arguments about the adverse effects of those products. Most health advocates’ reluctance in endorsing a harm reduction approach finds its origin in their genuine distrust vis-à-vis tobacco manufacturers (just think about their historical record of lies) which are perceived as incapable to produce and market safe products (just think about the ‘light/mild’ saga). Yet electronic cigarettes are not manufactured and marketed neither by the tobacco industry nor by the pharmaceutical industry. At least for now. The commercial success of electronic cigarettes, as recreational nicotine devices capable of closely mimicking the act of smoking, might indeed represent the new frontier of smoking, rectius vaping. It would be surprising should the tobacco companies won’t seize this chance by developing safer technologies and progressively begin marketing 'brand e-cigarettes'. Should society be against safer alternative to tobacco just because this will guarantee big tobacco future revenues?

 

Future regulatory policy on e-cigarettes and other alternatives to tobacco should be guided more by scientific evidence, i.e. how these products score as compared to conventional tobacco products, than by an ideological and revanchist approach against Big Tobacco. This is especially the case should e-cigarettes prove capable of reducing toxic exposure and help individual smokers to quit.