Electronic cigarettes: smoke without fire?
“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.
- FDA, (2009). “FDA and Public Health Experts Warn About Electronic Cigarettes”, press release, 22nd July 2009.
- Broadstock, M., (2007). “Systematic review of the health effects of modified smokeless tobacco products”, NZHTA Report 2007; 10(1).
- Sedghi, A., (2012). “The tobacco atlas of the world”, Guardian Online, 23rd March 2012.
- Furberg, H., et al, (2005). “Is Swedish snus associated with smoking initiation or smoking cessation?”, Tobacco Control, 2005;14:422-424.
- Britton, J., “Should doctors advocate alternative sources of nicotine? Yes”, BMJ, 15th February 2008, 336:358-9.
- American Council on Science and Health, (2012). “Irrational ‘health’ policy works against smokers in the EU”, ACSH Dispatch, 24th September 2012.
- Kieley, A., (2012). “Electric Slide”, Deutsche Bank Industry Report, 20th September 2012.
- 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).