Should electronic cigarettes be as freely available as tobacco cigarettes? NoBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3840 (Published 14 June 2013) Cite this as: BMJ 2013;346:f3840
Amid the feverish embrace of electronic cigarettes, come several statements by the tobacco industry that should cause public health proponents of such products to get a grip. For example, the chief executive of Reynolds America told shareholders in November 2012, just six months before entering the e-cigarette market, “We have a little mantra inside of the company . . . which we call the 80-90-90 . . . We spend about 80% of our resources in the combustible space. The combustible space is still 80%, 80+% of our operating income . . . [and] 90% of the organizational focus . . . And despite a lot of these new innovations that you see coming out, 90% of our R&D [research and development] budgets are actually directed at the combustible category . . . That is the category that’s still going to deliver a lot of growth into the future.”1
Big tobacco is not investing in e-cigarettes to wean itself off cigarette sales. Its recent
oleaginous rhetoric about them saving lives is utter duplicity. None of the big companies now in the e-cigarettes market have desisted from virulent opposition to policies that are known to reduce smoking. None has declared accelerated targets for reducing cigarette sales. As with other forms of smokeless tobacco, big tobacco wants smokers to use e-cigarettes as well as cigarettes, not instead of them. Its five goals are widespread dual use; retarding smoking cessation; resocialising public smoking back into fashion from its forlorn exile outside buildings; conveying to young, apprehensive would-be smokers that nicotine is a benign drug; and welcoming back lapsed smokers.
If big tobacco succeeds with any of these ambitions, e-cigarettes may cause a net increase in population harm. Urged on by myopic health professionals who seem to have lost any population health focus they might have had, this may become one of the biggest blunders of modern public health.
Public health enthusiasts for e-cigarettes see their promise as a way to get smokers to quit or reduce toxic exposure, but they seem blasé about the other possible effects described above. There are many impassioned, vocal testimonies that e-cigarettes have helped many thousands to quit or cut down smoking. But the first prospective study found that although smoking cessation and harm reduction motivated many e-cigarette users, there were no differences in smoking quit rates between e-cigarette users and non-users.2 And importantly, cutting down cigarettes rather than quitting confers little if any health benefit,3 so dual use may be as bad as continued smoking in terms of health outcomes.
Regulation is required
So how should we respond to e-cigarettes? The first step must be to move beyond anecdotal testimony and naive optimism and study large populations to build the evidence about whether e-cigarettes do accelerate quitting and to quantify behaviours indicative of the important industry goals above.
Tobacco use may kill a billion people this century,4 largely because of tobacco’s historic treatment as an unexceptional item of commerce and, later, decades of glacial action by governments failing to regulate this dangerous consumer product. But in the past 50 years, we have learnt much about how to reduce tobacco use—for example, only 15.7% of Australians aged 15 or over now smoke daily,5 and youth smoking has never been lower.6 We are finally pulling access to tobacco products back to where it should have started: expensive, highly regulated, non-advertised, plain packaged, and out of retail sight.
We should make none of the many disastrous mistakes made with cigarettes in the name of allowing e-cigarettes to compete better with cigarettes. We should start by not assuming they are benign items of commerce. Drug companies have long been able to sell nicotine in small doses as a quitting aid but have never tried to register high dose products. Their awareness of the role of nicotine in apoptosis, angiogenesis, inflammation, and cell proliferation7 8 9 has always put the brakes on any temptation to have regulatory agencies allow them to sell products with doses that genuinely compete with cigarettes. So why should e-cigarettes, for which users can create their own e-juice, escape such regulation?
Many smokers want to access e-cigarettes to quit or reduce risk, and they should not be denied this opportunity. But the needs of often desperate smokers must not become the tail that wags the dog of tobacco control policy, putting at risk the massive gains we have achieved. The advent of e-cigarettes provides a perfect pretext to introduce a form of user licence for nicotine products in the same way that access to potent drugs has long required a temporary licence (a prescription) for those who need them.10 This would balance the right to use e-cigarettes with all the constraints and disincentives that are now, and should be further, applied to cigarettes. For countries where e-cigarettes are virtually “off the leash” this will probably be impossible. But for most nations that have acted cautiously, e-cigarettes may in fact turn out to be a Trojan horse, stimulating regulators to take more seriously the regulation of all tobacco and nicotine products—not just pharmaceutical nicotine—regardless of the motive of the individual user or the stated and unstated motives of the manufacturer.
Cite this as: BMJ 2013;346:f3840
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Read Jean-François Etter’s side of the debate at doi:10.1136/bmj.f3845.
Provenance and peer review: Commissioned; not externally peer reviewed.