Simon Chapman on e-cigarettes: the best and the worst case scenarios for public health

simon_chapmanUse of electronic cigarettes (e-cigs or Electronic Nicotine Delivery Systems—ENDS) is showing exponential increase in some nations. Their regular use remains marginal in Australia, where the sale of nicotine liquid is banned  (personal imports are legal only if the importer needs nicotine for therapeutic purposes—including to assist with the cessation of smoking. Legal importation of e-juice would require a prescription). There is considerable energy going into envisioning the likely benefits and harms of their proliferation. In this first of three blogs, I paint the best and worst case scenarios. This week, I participated in a WHO meeting focused on e-cigarettes and have recently edited a special supplement of reviews on the issues involved by US Food and Drug Administration scientists. It will be published soon in Tobacco Control.

Best case scenario

There would be massive, rapid migration of current smokers into vaping. The scale of this would be akin to that which occurred when digital cameras replaced film cameras. We’d see unparalleled declines in smoking caused disease, starting with cardiovascular and respiratory diseases, and followed years later by declines in smoking-caused cancers where the latency periods between exposure and disease onset are longer. The overwhelming proportion of vapers would be smokers whose principal motivation for vaping was to stop smoking. While some might vape and smoke (“dual users”) for a short period, nearly all would completely stop smoking. Early research showing dual use as the most common pattern, would be revealed as a transitory part of the natural history of smoking cessation.

There would be homeopathically small levels of vaping uptake among ex-smokers and children who would have never smoked or used any form of nicotine. Longitudinal studies of those children who did start vaping would show negligible transition to smoking. Importantly, smoking children would, like adults, use vaping as a gateway out of smoking, not into it.

Most vapers would also stop vaping. This would eliminate any pre-cancerous risks of deep nicotine inhalation 200 times a day—73,000 times a year. This review noted, “Nicotine … deregulates essential biological processes like regulation of cell proliferation, apoptosis, migration, invasion, angiogenesis, inflammation, and cell-mediated immunity in a wide variety of cells, including foetal, embryonic, and adult stem cells, adult tissues as well as cancer cells.” There would also be reductions in the cardiovascular effects of vasoconstriction caused by nicotine. This paper describes nicotine’s impact on genes involved in metabolic and cellular processes.

But thankfully, continued research would indicate that the levels of exposure to nicotine from vaping was akin to health risks of coffee drinking. Continuing research also affirms that secondhand vape is inconsequential to any health outcome, despite particle sizes of vape being comparable to that in cigarette smoke. August scientific bodies like the International Agency for Research in Cancer affirm this in major reviews. Public awareness of this reduces antipathy to vaping in enclosed areas, and vapers accordingly feel less anti-social and welcomed into areas from which smoking is exiled.

The tobacco industry, seeing its tobacco sales in free fall, decides to hoist the white flag, divests themselves of smoked tobacco products, and drops all global opposition to effective tobacco control like plain packs and tax rises.

As smoking disease rates plummet, the inventors of e-cigs share the Nobel Prize for Medicine. The history of tobacco control has a final chapter on the triumph of harm reduction and the role of innovation. E-cigarettes have made smoking history.

Worst case scenario

Global uptake of e-cigarettes would be on the scale of cell phones. Most smokers would switch, but many people who would have never smoked—including children—would start vaping, first attracted by its coolness and “no risk” hype, and then maintained by nicotine dependency.

Smoking cessation stalls after a continual 40 year decline because most smoking vapers also keep smoking. Many smokers who would have otherwise quit would prevaricate and convince themselves that cutting back by using e-cigs rather than quitting was good enough. The numbers who stop smoking are easily eclipsed by the number taking up vaping who have never smoked. Significant proportions of these having become nicotine dependent, drift into smoking. They might have run out of e-juice, find the rigmarole of buying, loading, and refilling capsules too much hassle. Or most likely get curious about how smoking compares. Many find the nicotine jolt from cigarettes more satisfying than that from vaping. The net impact of all this would be a massive increase in smoking prevalence and vaping.

Governments would allow vaping companies and Big Tobacco (all its companies now have vaping lines) to advertise. The very same themes used to promote cigarettes are used to sell e-cigs. The smoking “performance” is re-socialised  and renormalized, signifying everything that smoking did 50 years ago: elegance, sexuality, modernity, freedom. A teenager without a highly personalised e-cig is about as gormless as it’s possible to imagine.

All indoor smokefree areas allow vaping, but slowly emerging evidence about its harms meets the decades long resistance and self-absorbed “vapers rights” arguments we saw with cigarette smoke. Smokers light up under the cover of a vaping-allowed policy in smokefree indoor areas, but brandish e-cigs to nightclub security staff when confronted. Smokefree policy collapses as unenforceable.

Those in public health who threw all caution to the wind, and vilified those who wanted good evidence to lead policy are written into public health history as overly excitable amnesic or myopic quislings, wittingly or unwittingly orchestrated by commercial interests.

Continual lung basting over years with nicotine and fine particles is revealed in longitudinal studies to be far from benign, but by then the imagined benevolent genie is well out of the bottle and showing himself to be a different shade of evil.

The genie is probably now out of the bottle in parts of Europe and the USA. Many other nations are opting to wait and see what this natural experiment shows. In the meantime, controlled models of e-cig access for adult smokers, like prescribed drug models, would be a sensible interim measure.

See also:

Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

Simon Chapman AO PhD FASSA is professor of public health at the University of Sydney and for 17 years was deputy editor and editor of the BMJ’s Tobacco Control.

  • Ed of Ballsworth

    Chapmans worst case scenario is a little far fetched. It’s pretty obvious to anyone who is objective and actually cares more about peoples health than destroying tobacco co.’s that the positives far outweigh any negatives..

  • The main problem with this is that it neglects the risks associated with Chapman’s caution. He thinks this is responsible, but in fact it is reckless, given the dominance of the incumbent cigarette market in supplying recreational nicotine. In the name of managing small and implausible e-cigarettes risks down to a negligible level, he would lose the potentially large health gains associated with substantial migration of the ongoing cigarette market to vapour products.

    The real worst case scenario is not the one given by Chapman. It is that the reckless and asymmetric loss aversion of zealous regulators will wrap these products in so much red tape, restrictions and burdens that they make the products less attractive, throttle innovation, turn off users and keep the smoking industry alive. The worst case is not people getting ill from vaping in mysterious ways we hadn’t thought of, but that they get ill in well-established ways from more smoking that would otherwise have been avoided.

  • dodderer1

    Snus has been used in Sweden for decades and has been shown to have a net benefit but these health ‘experts’ still ban it elsewhere.They are anti-tobacco industry;public health is irrelevant

  • Threthny

    Until e-liquid with nic is legalised for retail sale in Australia we will see little or no potential benefits manifest. The only people that would benefit would be the internet-savvy people able to source their nic from OS.

    The smoker with a casual interest in vaping would be a lot less likely to make the switch when there’s a lack of retail outlets.

    I am glad you’ve changed your tune irt dual-use, but its not actually clear if you actually believe that because of the worst/best scenario format you’ve chosen to use.

  • Sue Wilson

    Unfortunately, we will never see the best case scenario. This was a real possibility and could have enabled the biggest public health success since John Snow had the foresight to remove the pump handle in Soho. But, scaremongering and industry protectionism have already managed to score two own goals. Firstly, they have convince many current smokers that vaping may be dangerous and it is safer to continue smoking. Secondly, they have managed to get measures introduced into the TPD that will ensure that those ENDS which are an effective substitute for cigarettes will no longer be available.

    The rapid increase in the number of ENDS users (vapers) has not been driven by the tobacco companies but by word of mouth and new companies. It has previously been noted that the ENDS market is one of very rapid innovation. The tobacco companies have started to move into the market, having seen the writing on the wall, but are focusing on the products that look like cigarettes (cigalikes) and have limited effectiveness. It is very unlikely that they will be adaptable enough to keep pace with the developments in the market (unless, of course, EU and national governments implement regulation that lead to innovation being curtailed). It could be suggested that it is in the interests of tobacco companies that regulation ensures that only cigalike products are available; they can then take over this market as well as maintaining their base of smokers. It could also be suggested that it is in the interests of the pharmaceutical companies that the rapid growth in the use of ENDS is curtailed; they have already observed a reduction in profits from the sale of NRT.

    Given that it is widely acknowledged that vaping is several orders of magnitude safe that smoking cigarettes, measures to dissuade smokers from trying this alternative, or that restrict the availability of effective ENDS, can be nothing other than a public health disaster.

    Competing interests: I have been a vaper for almost 3 years after smoking for 40 years. Like many of the 20% of the population who continue to smoke, I never really wanted to give up. I tried a cigalike, saw it had potential and rapidly moved on to using what are now called 3rd generation devices (and will be banned by the latest revision to the TPD). I have not smoked tobacco cigarettes since I started vaping.

  • Sandi

    The only way they would find the nicotine jolt more satisfying with tobacco is if the eu insist on keeping the maximum amount of ejuice at 20 mg.

  • sharon

    The current approach to the “end game” of smoking appears to be about stopping teenagers from taking it up, eventually the older smokers will quit or die and the end game is achieved but it is unrealistic. advertising bans, increasing taxes, smoking bans, plain packaging have not stopped teenagers from experimenting because that is what teenagers do, they experiment with smoking, alcohol, drugs. The focus need to be on finding ways for older smokers to get off combustable tobacco more easily which is where ecigs fill a role and gen1 ecigs have been proven to be slighly more effective than patches so it is yet another tool. why are you not concerned with teenagers getting addicted to nrt and then becoming smokers? It’s freely available from supermarkets or should we ban all vegetables containing nicotine too?

    It is time for antitobacco to take a fresh look at what they are doing, and rather than attacking smokers efforts to get off cigarettes by any means, it should be encouraged and applauded as a good sign. it goes to show that smoking is not something most smokers want to take to their grave, they are showing initiative by trying something new and it costs the public purse nothing. NRT has been around for decades and it has not worked for the majority of smokers so it’s time to open our eyes and see what ecigs can do for the quit rates.

  • Simon_Chapman

    Sharon, I encourage you to look at the data on what has happened to teenage smoking in nations where tobacco control in taken seriously. Far from the picture you paint, teenage use is the lowest ever recorded. In Australia only 2.5% of 12-17 year olds smoking daily. Read the next installment later today and you will find a link to that data. Similar if not quite so good scenarios apply in Canada, the US & the UK I believe.

  • sharon

    however, current approaches have not eliminatednew smokers or teenage smoking which was my point and likely never will. this is why this strategy will not reach the “end game”. If it truly worked then no one under 40 would be smoking now but still there are young smokers around. what I suggest is that you need to look at other possibilities to get existing smokers off tobacco more easily, then it becomes a moot point about teens taking it up if they have a way back out instead of smoking for decades and this is where ecigs can be effective. This issue is about people and their health, but you approach it solely on numbers (people are not numbers or statistics)


    Completely agree. There are many people who argue that electronic cigarettes are bad for your health too, and while I don’t think they’re healthy I think they’re less harmful than regular cigarettes.


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  • It is nice to see an article dedicated to this important topic. Thank you for sharing.

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  • In France, for example, cigarette électronique is growing up very fast. There are new stores poping up every week.