Electronic cigarettes: the renormalisation of nicotine use

We agree with McKee and Capewell’s article on Public Health England’s report.1 Unfortunately, the debate focuses on the potential harm reduction among dual users and diverts attention away from the harms of e-cigarettes,2 ignoring their impact on naive users, especially adolescents.

Despite the complete ban on tobacco advertising since the 1970s, television and radio marketing of e-cigarettes is permitted. In 2014, around 18.3 million adolescents in the US were exposed to e-cigarette marketing messages,3—68.9% of the participants in the 2014 National Youth Tobacco Survey. Concurrently, e-cigarettes became the leading tobacco product used by American adolescents.4 Interestingly, the survey found that adult smokers and recent quitters who use e-cigarettes were significantly more likely than non-users to have the urge to smoke conventional cigarettes after viewing e-cigarette advertisements (83% v 72%).5 A study of children found that non-smokers who used e-cigarettes were more likely than non-users to smoke tobacco products at follow-up.6 This is not surprising, given that e-cigarettes supply the same addictive substance (nicotine) as other tobacco products.

Thus, e-cigarettes might lead to a rebound increase in other tobacco product use through two possible mechanisms—indirectly through marketing messages and renormalisation of smoking,3 4 5 and directly through the nicotine gateway theory.6 Therefore, if e-cigarettes have a role in smoking cessation they should be regulated like a medicine.1