Regulation of electronic cigarettes

The World Health Organization statement on electronic nicotine delivery systems (electronic cigarettes)1 was met with apparent disagreement from both Public Health England (PHE) and Action on Smoking and Health (ASH), a UK public health charity.2 WHO, supported by many professional bodies,3 4 calls for regulations that impede the promotion of e-cigarettes, minimise their potential health risks, prohibit unproved health claims, and ban their use indoors. By contrast, PHE and ASH, which have been more positive about them, do not support a ban on their use indoors.

Many critics of WHO’s position are from the harm reduction community and see e-cigarettes as a useful contributor to tobacco control efforts. But these critics seem unable to decide whether e-cigarettes are a short term medical aid to quitting smoking or a consumer good, to be used in the long term. WHO’s critics seem to be challenging the presumption of “at least do no harm” that is implicit in the regulatory requirements that apply either to new drugs or consumer safety.5 What is anyone to make of it all?

A plethora of small scale e-cigarette producers have set up business during the past five years, promoting devices through advertising and social media. Images aimed at young people are reminiscent of those previously used by the tobacco and alcohol industries.6 7 8 More recently, tobacco manufacturers have rushed to buy up e-cigarette manufacturers.9

Things came to a head in May this year. A letter with 53 signatures was sent to WHO’s director general, Margaret Chan, calling on the organisation to exclude e-cigarettes from regulation under the Framework Convention on Tobacco Control.10 This was met with a referenced letter to Chan from 129 public health and medical authorities expressing serious concerns about e-cigarettes and urging WHO to adopt an evidence based approach to their use.1 11

Drawing on a systematic review of the available evidence,12 WHO concluded that e-cigarettes cannot be rated as safe at present because of concerns about passive exposure, nicotine’s role as a possible carcinogen, and safety concerns about other substances they may contain, including lead. One e-cigarette liquid was recently withdrawn from the market after tests found it was potentially harmful.13 Stanton Glantz, professor of medicine at the Center for Tobacco Control, University of California San Francisco, says “there is no justification for reintroducing these toxins indoors after we spent 30 years getting rid of them.”14

The arguments about e-cigarettes have brought to the fore perennial tensions between individual patient care and the wider population perspective. Although there are anecdotal reports that some smokers find e-cigarettes helpful in reducing smoking, so far there is no robust evidence that e-cigarettes are better than existing support, such as NHS quit services. There is also concern that dual users who continue smoking are not protected from cardiovascular risk. WHO says much more research is required.

Although e-cigarettes may benefit some smokers, the public health community is concerned about their potential effect on population health and tobacco control. Areas of concern include how to prevent nicotine initiation among young non-smokers while maximising benefits of e-cigarettes for smokers who want to quit. The tobacco industry’s integration with e-cigarette manufacturers is not altruistic.

The psychology of substance use is firmly grounded in individual and social rituals. The products themselves touch primitive roots of oral gratification, which may be transferable from vaping devices to flavoured cigarettes. A recent report from the US Centers for Disease Control seems to support the idea that sweet flavoured vapours can lead on to tobacco.15

Many, seemingly well informed, people appear willing to suspend disbelief about the tobacco industry’s goodwill. This issue is as much about commercial politics as science. Let us get the science right by making sure all vested interests are in the open, as we seek to improve the public’s health. To quote the poet Piet Hein, “Problems worthy of attack prove their worth by hitting back!”16