Intended for healthcare professionals

Observations Yankee Doodling

Big Tobacco lights up e-cigarettes

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3418 (Published 24 May 2013) Cite this as: BMJ 2013;346:f3418
  1. Douglas Kamerow, chief scientist, RTI International, and associate editor, BMJ
  1. dkamerow{at}rti.org

Good news or bad?

E-cigarettes, more formally electronic nicotine delivery systems, were introduced in 2007. They are battery powered, cigarette shaped devices that vaporize nicotine so that it can be inhaled. E-cigarettes are currently a relatively tiny market. In the United States they accounted for about $500m (£330m; €390m) in sales last year, perhaps 0.5% of tobacco receipts.1

That is changing. The tobacco company Lorillard purchased the leading e-cigarette maker Blu last year. Reynolds American is expanding marketing of its Vuse e-cigarettes, and Altria, the largest US tobacco company, has announced that it will enter the e-cigarette market later this year with its own product.1 Marlboro e-cigarettes, anyone? The game is on.

This, of course, has public health advocates terrified. Just when we had Big Tobacco on the run, with US sales falling 3-4% a year, along comes a new product that may save them—as well as maintain the nicotine addiction that they depend on for sales. In fact, tobacco industry sales were down more than 6% last year, due in no small part to the increase in e-cigarette sales. Hence the recent acquisitions and announcements.1

Let us count the ways that e-cigarettes are upsetting. First and foremost, they are increasingly available and cheap. You can buy them, singly or in packets, in many US convenience stores for about half the price of conventional cigarettes. They are flavored, leading to fears that they will attract younger, first time smokers, or “vapers,” as they call themselves (because the “smoke” is actually vaporized liquid nicotine solution). They have a high tech image: rechargeable cigarettes with batteries, what could be more desirable? They are not as offensive to others as tobacco cigarettes: their vapor doesn’t smell bad, it produces no ash, and they don’t give you bad breath. They are being promoted on cable TV and the web (see examples on YouTube at http://bit.ly/19799LC and http://bit.ly/10phvaU) by sexy movie and rock stars, who urge us to “take our freedom back.” Further, we don’t really know what is in e-cigarette cartridges; some manufacturers list ingredients, others don’t. Studies measuring the content of the cartridges have found varying nicotine levels as well as unlisted, dangerous ingredients.2 3

What permits most of the above is the fact that e-cigarettes are almost completely unregulated and untaxed. The US Food and Drug Administration tried and failed to classify them as drug delivery devices, which it could regulate. Now the FDA says that it will regulate e-cigarettes as tobacco products, but it has already missed one deadline for announcing these rules and recently opined that “further research is needed” before it proposes regulations.1 Meanwhile, stiff taxation, a potent weapon against conventional cigarettes, barely applies to e-cigarettes. Only one US state currently taxes e-cigarettes, and there is no federal excise tax on them at all.

Many of the ways smokers use e-cigarettes are worrisome. Some people use them as a substitute for tobacco cigarettes when they need nicotine but can’t smoke because they are at work, at a bar, or at home with objecting family members. E-cigarettes thus help maintain the smoking habit and reduce incentives to quit. Others use them as a way to cut down but revert to tobacco cigarettes on finding them unsatisfactory. Younger vapers start smoking with e-cigarettes, lured by the movie star adverts, implied safety, flavored choices, and permissibility of use anytime and anywhere.

But we can envisage helpful uses for e-cigarettes too, generally as smoking cessation aids. Although it is strictly forbidden to advertise such uses (that would immediately put them under FDA jurisdiction), the e-cigarette companies subtly imply such a use for their products. Pilot studies have started to appear that use e-cigarettes in smoking cessation efforts, and doubtless full clinical trials are on the way.

Finally, as with the extended use of other nicotine replacement products, which is discouraged but clearly better than resuming smoking, even we public health nuts have to admit that if you’re going to smoke it is probably a lot better to be a vaper than a tobacco smoker. Especially if the content of the nicotine cartridges is regulated and under FDA control, I’d much rather put relatively pure nicotine into my lungs than the mix of ingredients found in burned tobacco. Further, if they are produced by a regulated Big Tobacco industry, which has deep pockets and understands the consequences of running afoul of (yet to come) regulation, you can hope that what you get is what’s on the ingredient list.

Which is why I asked the question at the outset whether it is a good or a bad thing that the major tobacco companies are jumping into the e-cigarette market. It seems to me that the best possible outcome at this point is for the FDA to regulate the crap out of e-cigarettes—in both senses of that coarse construction: regulate them heavily, and get the poisons, flavorings, and everything but nicotine out of them. Meanwhile, television advertising should be banned, age and availability restrictions enforced, and e-cigarettes heavily taxed, at levels similar to those for tobacco products. And we desperately need clinical trials and observational studies to learn more about how e-cigarettes are being used and whether they are helpful in smoking cessation efforts.

Now that the vapor is fully out of the cartridge, we’re not going to be able to get it back in. We need to make the best of a bad situation before it gets worse.

Notes

Cite this as: BMJ 2013;346:f3418

Footnotes

References

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