Use 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.
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.