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E-cigarettes and the marketing push that surprised everyone

BMJ 2013; 347 doi: (Published 26 September 2013) Cite this as: BMJ 2013;347:f5780

Rapid Response:

Re: E-cigarettes and the marketing push that surprised everyone

Martin McKee’s opinion piece and Clive Bate’s response highlight both the concerns and opportunities, respectively, which surround the emerging market in e-cigarettes. The reality is that we don’t know what will happen if e-cigarettes continue to be heavily marketed and largely unregulated as Bates desires, but there are reasons for concern.

If e-cigarettes are only used by smokers to reduce or quit their tobacco use or by those that would otherwise have taken up cigarette smoking, e-cigarettes would undoubtedly bring significant public health benefits.

Conversely, if smokers use e-cigarettes to sustain rather than reduce their smoking, if e-cigarette marketing and use re-normalises and re-glamorises smoking, if young people that would not otherwise have started smoking take up e-cigarettes and if e-cigarettes lead into rather than out of smoking, they will be detrimental to public health. While conventional cigarettes remain on the market, these are concerns that must be taken seriously particularly given the ways in which e-cigarettes are being marketed.

Currently, the majority of e-cigarette users in the UK are also cigarette smokers or ex-smokers [1], but this is a rapidly changing market and needs to be carefully monitored. Furthermore, while English longitudinal data show that smokers are increasingly using e-cigarettes in attempts to quit and cut down and that smokers using e-cigarettes are more likely to have tried to quit in the last year, there is, as yet, no evidence that e-cigarette use is linked to reduced consumption or enhanced quit success.[2][3] US data show that, at 7-months follow-up, e-cigarette users were significantly less likely to have quit than those who had never tried e-cigarettes,[4] while randomised controlled trial evidence indicates that e-cigarettes are no more effective than existing pharmaceutical nicotine products.[5] In short, therefore, there is as yet no hard evidence of the effectiveness of e-cigarettes as a quit product.

A further issue is transnational tobacco companies’ (TTC) interests in this area. While e-cigarette companies are currently largely independent of tobacco interests, the TTCs have begun to invest in this area just as they did in snus a few years ago[6]. While Bates suggests this move from tobacco to electronic cigarettes should be celebrated, recent research raises major concerns about TTC involvement in this broader nicotine market[6]. It shows that if the TTCs’ pattern of e-cigarette investments follows that of snus we can expect the TTCs to buy out all significant independent e-cigarette operators and stifle any genuine competition between electronic and tobacco cigarettes. This would have serious implications for the ability of e-cigarettes to benefit public health and serve only to maintain the status quo in favour of cigarettes.[4] This research also highlights a secondary danger of TTC involvement in the nicotine/e-cig market - that it enablesTTCs, by presenting themselves as purveyors of nicotine rather than tobacco products, to negotiate a seat at the policy table and thereby undermine Article 5.3 of the Framework Convention on Tobacco Control which aims to protect public health from vested tobacco interests.[6]

The competition issue outlined above is complex. While regulation of the e-cigarette/nicotine market should reduce the likelihood of the negative consequences outlined above emerging from the burgeoning e-cigarette market, the anticipated regulation would be powerless to address the issue of competition. Ironically, it could aggravate the situation by making it harder for small, independent companies to compete. Perhaps, however, the solution is not to abandon regulation but to address the competition issue by making a case to the Office of Fair Trading that having TTCs invest in e-cigarettes further reduces the already extremely limited competition[7] in the recreational nicotine market.

Anna B Gilmore & Silvy Peeters, Tobacco Control Research Group & UK Centre for Tobacco and Alcohol Studies, University of Bath.

[1] ASH fact sheet. Use of e-cigarettes in Great Britain among adults andyoung people (2013). May 2013.
[2] West R, Brown J. Latest trends on smoking in England from the Smoking Toolkit Study. Updated 2nd Sept 2013.
[3]West R, Beard E, Brown J. Trends in use of electronic cigarettes in England 2011-13. Smoking Toolkit study.
[4]Bullen C, Howe C, Laugesen M, McRobbie H et al . Electronic cigarettes for smoking cessation: a randomized controlled trial. Lancet September 7, 2013
[5] Vickerman KA, Carpenter KM, Altman T, Nash CM, Zbikowski SM. Use of electronic cigarettes among state tobacco cessation quitline callers. Nicotine and Tobacco Research
[6] Peeters S, Gilmore AB. Transnational Tobacco Company Interests in Smokeless Tobacco in Europe: Analysis of Internal Industry Documents and Contemporary Industry Materials. PLOS Medicine, Sept 2013.
[7]Gilmore A, Branston R, Sweanor D. The case for OFSMOKE: how tobacco price regulation is needed to promote the health of markets, government revenue and the public. Tobacco Control 2010; 19; 423-30.

Competing interests: AG and SP have received funding from the US National Institutes of Health National Cancer Institute and the European Union to research tobacco industry interests in harm reduction.

02 October 2013
Anna B Gilmore
Professor of Public Health
Silvy Peeters
University of Bath and UK Centre for Tobacco COntrol Studies
Claverton Down Road, Bath, BA2 7AY