Electronic cigarettes: smoke without fire?

24 October 2012 by Victoria Charlton, posted in Tobacco

“Giving up smoking is the easiest thing in the world. I know because I've done it thousands of times.” Mark Twain          

For my first blog post here on SciLogs, I thought I’d choose a subject that we can all agree on.  Smoking.  It’s bad, right?  I mean, really bad.  Obviously.  But are there any exceptions?  Are all cigarettes really unequivocally, indisputably, “disgusting-habit-breath-stinks-probably-going-to-kill-you” bad, or are some just “waste-of-money-don’t-see-the-point-you’re-feeding-an-addiction” bad?  As a famous novelist once (almost) said: are all cigarettes equal, or are some cigarettes more equal than others?

A buzz term doing the rounds in tobacco control circles at the moment is ‘harm reduction’, a policy that attempts to jump right to the end-result of smoking – that is, more often than not, horrible illness and death – without worrying too much about the causes.  The theory goes something like this.  Nicotine is really very addictive, and experience shows that people are not very good at giving it up, regardless of how many scary pictures of tar-blackened tumours you put on the front of cigarette packets.  Attempts to prevent people from smoking in the first place also haven’t been terribly successful, particularly in the poorest groups in society, with the result that smoking is now a major cause of health inequality on top of everything else.  The upshot of all this is that the tobacco industry is now costing our health systems billions of pounds that they really can’t afford.  So, goes the logic of harm reduction, let’s focus less on helping people to entirely quit smoking, and more on minimising the overall damage that smoking – or rather, nicotine addiction – causes.

Now, this all sounds eminently sensible to me.  Obvious harm reduction strategies include minimising the damage caused by second-hand smoke by banning smoking in public places, for example.  Or encouraging users to substitute the nicotine from cigarettes with nicotine from less hazardous sources – such as unexploded hand grenades, for instance, (or, more conventionally, nicotine patches and gums). A no-brainer, surely, for those who can manage it?

Where things get more controversial is where “less harm” stops meaning “no harm”.  Take electronic cigarettes, for example.  While relatively little research has been carried out to date, an FDA analysis of e-cigs currently on the market did find traces of several carcinogenic and toxic chemicals, raising concerns about safety1.  Similarly, snus, a form of moist tobacco snuff popular in Sweden, has been linked with an increased risk of oesophageal cancer and heart disease2.

However, snus has also been linked with an increased risk of, well, not dying from smoking, with Sweden reporting only half as many smoking-related deaths as the UK in 2011 3,4.  And let’s be honest, while sticking a tobacco-stuffed tea-bag under your upper lip for hours at a time (yes really) is unlikely to enhance oral hygiene, it’s a long way from challenging good old-fashioned cigarettes for the title of Miss (Single Biggest Cause of Preventable Death in the Developed) World.

By far the most controversial harm reduction strategy, however, is to simply keep smokers puffing away on a slightly less toxic version of Old Faithful.  This tactic has been embraced by Big Tobacco in the past, with the success of lights and menthols in the 1990s proving that an attractive market does exist for such ‘safe’ alternatives.  (And believe me, there are not enough quote-marks in the world to suitably caveat my use of that word).  Unfortunately, in reality, such products back then were little better than their ‘unsafe’ predecessors, contributing to Big Tobacco’s decidedly grubby reputation for trying to hook consumers on their products at all costs.  Nevertheless, technology moves on, and if consumers have the will to smoke a cleaner product, it’s almost certain that industry will eventually find a way.

Because it’s important to remember, I think, just how bad cigarettes really are.  It is estimated that one in every two long-term smokers will die as a result of their habit, potentially leading to one billion deaths from smoking in the 21st century if the problem continues to go unchecked.  As such, even a small reduction in the toxicity of the products that people are smoking could save thousands of lives.  And there is evidence to suggest that alternatives such as e-cigs could be a valuable tool in helping smokers to give up the tar, if not the nicotine 4.  Because it is also worth remembering that smokers are addicted to much more than just chemicals.  Nail-biters like me don’t gnaw on our fingers because we’re addicted to keratin – we do it because it’s a learned behaviour.  So it’s easy to see how e-cigs, for example, might quite literally offer a life-line to those smokers simply unable to kick the habit.  (Interestingly, as a slight aside, it is estimated that 77% of UK smokers want to give up smoking, and 78% have tried and failed5.  Which makes me wonder about the thought process of that 1%).

So, we should be expecting to see a lot more of these alternative products on the market in the future then, right?

Wrong.  Snus is already banned across the EU, with the exception of Sweden, which pluckily demanded derogation (exemption) from the ban when it joined the Union in 1995.  In warmer climes, electronic cigarettes are also banned in Australia, Brazil and Thailand, to name but a few, because of their unproven safety profile.  (Unlike cigarettes, of course, which have been entirely proven to be unsafe.)  What’s more, a leaked draft of the EU’s revised Tobacco Products Directive seems to suggest that all smokeless nicotine-containing products may well be banned outright across member states within a few years6.  In Europe then, the cheerfully-named “quit or die” approach looks to be the tobacco control strategy of choice.

Across the Pacific in the US, things are a bit more liberal.  In 2009, Congress granted the FDA authority over all tobacco products, opening the door to a less prohibitive but more closely regulated approach than the one currently being pursued in the EU.  Under this model it seems likely that all tobacco products, including smokeless products such as e-cigs and snus, will eventually be regulated in a similar way, potentially (and very sensibly) leading to standardised product design, restrictions of sales to minors and prohibition of sweet flavourings likely to appeal to children and adolescents7.  (Bubblegum-flavoured ciggy, anyone?)  Crucially however – particularly for the nicotine-addicts currently using these products – US policy should keep such alternatives on the market.

Floating between these two approaches, both politically and geographically, is little old England.  And here, a storm looks to be brewing.  The government has repeatedly made noises about embracing harm reduction in its “radical” new approach to tobacco control, with the Behavioural Insights Team, the government’s infamous ‘nudge unit’, claiming that “if more alternative and safe nicotine products can be developed which are attractive enough to substitute people away from traditional cigarettes, they could have the potential to save tens of thousands of lives a year8”.  Nevertheless, as a member of the EU, the UK may well be expected to toe the party line and ban such products, leaving Europe’s millions of nicotine-addicted consumers choosing between those oh-so-healthy cigarettes, and a selection of nicotine-replacement treatments that just don’t hit the spot.  While for industry, the shut-down of the potentially lucrative smokeless market provides Big Tobacco with one less distraction from its core business of coupling nicotine-addiction with what is probably the most devastating consumer product of all time.  Fabulous.

We live in a safety-first culture, and in many ways that’s a great thing.  But safety is a relative term.  In some cases we recognise this, helping drug addicts to replace heroin with methadone without ever feeling the need to prove that the substitute is risk-free.  But in tobacco control, where the stakes are arguably even higher, there is a worrying trend towards reactionary policies that ban relatively safe products while leaving the real killer on the market.  To my mind, this is simply crazy.  The evidence may not yet be in on products such as e-cigs, but we should attempt to gather it before reaching our conclusions.  All cigarettes are not equal – and it’s time to stop treating them as though they were.

References:

  1. FDA, (2009).  “FDA and Public Health Experts Warn About Electronic Cigarettes”, press release, 22nd July 2009.
  2. Broadstock, M., (2007).  “Systematic review of the health effects of modified smokeless tobacco products”, NZHTA Report 2007; 10(1).
  3. Sedghi, A., (2012).  “The tobacco atlas of the world”, Guardian Online, 23rd March 2012.
  4. Furberg, H., et al, (2005).  “Is Swedish snus associated with smoking initiation or smoking cessation?”, Tobacco Control, 2005;14:422-424.
  5. Britton, J., “Should doctors advocate alternative sources of nicotine? Yes”, BMJ, 15th February 2008, 336:358-9.
  6. American Council on Science and Health, (2012).  “Irrational ‘health’ policy works against smokers in the EU”, ACSH Dispatch, 24th September 2012.
  7. Kieley, A., (2012).  “Electric Slide”, Deutsche Bank Industry Report, 20th September 2012.
  8. Cabinet Office, (2011).  “Behavioural Insights Team: Annual update 2010-11”. Available at: http://www.cabinetoffice.gov.uk/sites/default/files/resources/Behaviour-Change-Insight-Team-Annual-Update_acc.pdf (accessed 21st October 2012).

18 Responses to “Electronic cigarettes: smoke without fire?”

  1. James_F Reply | Permalink

    E-cigs may work for a minority and should be encouraged. However, until we either apply the enormous tax charge required to reflect the real cost of the associated health problems or charge smokers for access to NHS treatment, non-smokers will continue to foot the bill for smokers personal choices.

  2. Kausik Datta Reply | Permalink

    Warm welcome to Scilogs. I already love your writing style! This is a complex issue, as is any addiction. I have a friend who stopped smoking for seven years, before taking it up again; friends who had switched to e-cigarettes and switched back to regular cigarettes; and friends who smoke while driving because it apparently relaxes them. These are people across various nationalities, and all highly educated, working in healthcare or biomedical research fields (irony of ironies!). As you write more and more, I hope I'd be able to find some answers.

    Cheers!

    • Khalil A. Cassimally Reply | Permalink

      I have friends who need to smoke while in the loo for proper "passage"! I kid you not. As an aside, cigarettes are the only product that when used as per instructions will kill you.

      • Victoria Charlton Reply | Permalink

        Wow - that's worrying. Could this be the next global health crisis?! Talk about unintended consequences of public health measures...

  3. Suzi Gage Reply | Permalink

    Welcome to Scilogs, great post! I had always thought that snus was perfectly legal in this country, but advertising it was not, so as it couldn't be marketed, it didn't make financial sense to sell it, so no one did. I may be wrong though.

    I think harm reduction is a much misunderstood and potentially very useful tool to improve health. With regards to electronic cigarettes, a lot of research is going on at the moment, so hopefully we'll have a much better understanding of them soon. I did some research in to them and the nicotine liquid kept leaking all over my hands, not good! We are reviewing a paper by Polosa et al about e-cigs as NRT device in our journal club tomorrow, have you read that paper, and what do you think (Polosa et al, 2011 BMC Public Health)?

    • Victoria Charlton Reply | Permalink

      Thanks Suzi - I'll take a look at that paper. I just hope the regulation hasn't already overtaken the research in the EU and a couple of other countries.

      Re: snus, it's Directive 2001/37/EC that's the relevant one, but I have to admit I don't speak terribly fluent legalese, so you could be right on the advertising ban. I couldn't believe it when I found out how snus was used though - bizarre! Maybe it should be banned for yuk factor alone.

  4. GT Reply | Permalink

    The problem with the harm minimisation strategy is that some people who would never consider taking up traditional smoking would be prepared to try e-cigs, for example, because of the lower perceived risk. You could then potentially end up with even more people becoming addicted to nicotine than we otherwise would. The comparison with heroin/methadone is not really relevant as methadone is only available under strictly controlled circumstances ie to existing heroin addicts under medical supervision, whereas e-cigs would be freely available in shops.

    • Victoria Charlton Reply | Permalink

      Hi GT, thanks for the comment. I think that you make a very valid point - it might be that e-cigs do attract new smokers, in which case it would be sensible to regulate them in a similar way to methadone, for example, as part of a closely controlled cessation programme. But my point is that we just don't know if that's the case or not.

      Personally, it seems unlikely to me that e-cigs would have a net negative effect on public health. And banning e-cigs while continuing to allow people to smoke traditional cigarettes seems a lot like swerving your car to avoid a squirrel and then not even bothering to try avoiding the tree! But this is just a hunch, and I'd prefer it if policy decisions were made on the basis of hard evidence, whichever way they eventually turn out.

      Victoria

  5. sedeer Reply | Permalink

    I've suggested e-cigarettes to several smokers I know and have also been baffled by the fact that they're worried about the health consequences. I guess it's a combination of habit and preferring the devil you know, but it certainly seems like an odd response to me.

    Thanks for the well-written post; I look forward to reading more from you!

  6. Erik Reply | Permalink

    Although that is certainly true, "some people" are likely to do this, the numbers of such people is probably quite small. On the other hand, millions of people are taking up e-cigs, and current research, as well as common sense, shows e-cigs to be dramatically safer than regular cigarettes - both for users and innocent bystanders.

    Additionally, e-cig use provides for a fairly simple step by step reduction in nicotine levels consumed. The reduction is under control of the end user, and that end user by definition has already taken steps to improve their health by switching from burning tobacco.

    Alternatives such as gum, patches, or pharmaceuticals have proven to be by and large ineffective. Users of e-cigs can actually get off burning tobacco, enjoy the process, improve their health and save money.

    Trying to restrict or ban the use of e-cigs is truly myopic, particularly when the burning tobacco alternative remains readily available.

  7. Erik Reply | Permalink

    Above was in response to GT above, lamenting the few who would take up e-cigs that would not smoke regular tobacco.

  8. Melanie Reply | Permalink

    Great article. I definitely think "reduced harm" or in my opinion, "significantly reduced harm" is the way to look at electronic cigarettes. Sure, there still is some harm from the nicotine (unless you are smoking nicotine free..) but you're also eliminating tons of nasty chemicals found in cigarettes. I am staying open minded on the potential harms of e-cigs although really, they can't be anywhere close to the harm of cigarettes.

    Melanie

    • Erik Reply | Permalink

      I do appreciate your comment and your recognition of harm reduction from e-cigs. However, nicotine itself is not particularly harmful. In fact, new research shows that it can be effective in preventing and treating Alzheimer's as well as boosting cognitive abilities of elderly people just suffering from normal age associated mental decline. Nicotine actually boosts the growth of new blood vessels and this affect is being studied for use in treatment for diabetics to improve circulation. There are also are benefits for people suffering from depression due to a lack of dopamine or serotonin.

      So, we should be careful in characterizing nicotne as harmful in much the same way we would with caffeine, which is another highly addictive and potentially abusable drug - although no one is trying to prevent coffee drinkers from getting their morning fix.

  9. demin Reply | Permalink

    Its been great using such smokeless cigarettes.Thanks for such articles.I love electronic cigarettes

  10. Josh Reply | Permalink

    I agree that electronic cigarettes are less harmful for you to use. They do have harmful effects though as you stated. I think electronic cigarettes are the best alternative to smoking regular cigarettes out today. It helped me quit smoking after 27 years. I am thankful for their invention no doubt.

    • Joe Reply | Permalink

      In fact, the use of electronic cigarettes can not be called quit of smoking.

  11. joe Reply | Permalink

    actually, since there is no smoke, use of an e-cig cannot be considered smoking; therefor I'm obligated to offer my congrats to Josh.

    A little homework will show that there is no good reason to ban these products other than to save the tobacco industry. Once these go "mainstream", big tobacco is dead.

  12. Jon_b Reply | Permalink

    Thank you Victoria. At least this was an intelligent and measured piece of writing compared to the great anti-lobby. E-cigs are a lot less expensive as a habit - they also have a lot less harmful chemicals and no tar compared to tobacco. There is indeed a movement of self-interest against these by powerful voices. The quit somoking aid market is rumoured to be worth over £45 billion world-wide - taht means there is a lot at stake for the big drugs companies. For those that smoke and want to try something less damaging - just Google "electronic cigarette uk" - get one, try one. Also - see this:

    http://www.e-cigarette-forum.com/forum/campaigning-discussions/361242-eu-banning-e-liquid-looking-likely-email-prime-ministers-office-no-10-a.html

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