Intended for healthcare professionals

Rapid response to:

Head To Head

Should electronic cigarettes be as freely available as tobacco cigarettes? No

BMJ 2013; 346 doi: (Published 14 June 2013) Cite this as: BMJ 2013;346:f3840

Rapid Response:

Re: Should electronic cigarettes be as freely available as tobacco cigarettes? No

The question of the use of electronic cigarettes (e-cigs) and its regulation at the national and international (e.g. panEuropean) level concerns not only the physiological and toxicity aspects, e.g. the association between cancer and smoking, but also some relevant behavioral and psychological aspects, or their psycho-economic equilibrium. Within a community, behaviors spread according to schemes devoted to the search for a psychological balance. This means that a certain behavior will be more prevalent in some communities, the more they are perceived higher in benefits against low perceived costs or risks. The achieved equilibrium is given by the ratio between the number of individuals of a certain community who start a behavior, due to the perception of a psychological benefit, and those who still remain alien to it.

The introduction of tobacco products (and later cigarettes) in Western societies starting from the 16th century had a significant impact. The diffusion curves of cigarettes after the development of the tobacco industry at the end of 19th century show that we have suffered a real smoking epidemic, soothed by cultural traditions before (for example, due to religious or cultural-related limitations) and subsequently by regulations aimed to limit negative effects, once they were known. Being an additive, hence pathological behavior, the psycho-economic equilibrium was reached with great difficulty, as a result of particularly relevant evidence (e.g. the association between smoking prevalence and the epidemiology of lung cancer) and particularly stringent regulations as the smoking ban in public places.

Although many experts felt that a smoking ban would have increased the desire to smoke, the result has been a real success, thanks to the achievement of a new psycho-economic equilibrium, which has prompted many individuals to quit smoking or reduce the number of cigarettes smoked in order to avoid the unpleasant effects of abstinence. In addition, the forced abstinence leads many smokers to seek other ways to manage their negative emotions, which leads in turn to reduce nicotine addiction. Obviously, cultural and social changes might reshape this balance, for example by encouraging women and immigrants smoking, for whom it will be necessary to implement new and more targeted prevention and support programs.

Now the introduction of the electronic cigarette is likely to upset this precarious psycho-economic equilibrium achieved thank to a widespread effort.

It is then necessary not only to understand the toxicity of these new ways of smoking, but also its impact on the mind’s smokers. For example, how the use of e-cigs will affect tobacco smoking? Will e-cigs lead to a new e-smoking epidemic?

The widespread e-cigs communication and advertisements try to reduce the perceived smoking-related risks, by highlighting the benefits of e-smoking. In this way, the free diffusion of e-cigs might scramble the previous equilibrium, without a full and evidence-based awareness of the related consequences on health.
Eventually, a different consideration deserves the use of e-cigs in patients or people at high risk (e.g. due to heart problems), for which quitting traditional tobacco cigarette smoking may lead to a considerable reduction of risk, with clear benefits both for individuals and community, also from and economical point of view. However, this issue strongly suggests the need for a shared and evidence-based regulation able to discern the therapeutic use of e-cigs from the ad libitum use of them, as well as social, behavioral and psychological differences in the adoption of nicotine-based and nicotine-free e-cigs.

Research and regulations are then needed in order to elude a new form of behavioral epidemic, avoiding thus the swapping of an addiction with another one. In particular, we need to know how to guide the contemporary society to a new and efficient psycho-economic equilibrium without wasting all the success achieved during last years in western countries.

Competing interests: No competing interests

18 June 2013
claudio lucchiari
Researcher in Cognitive Science
Gabriella Pravettoni
Università degli studi di Milano, Department of Economics
Via Conservatorio, 7, 20122 Milano, Italy