20 Mar, 14 | by BMJ
Discussion about e-cigarettes on social media, the blogosphere, and vaping chatrooms is dominated by impassioned accounts from former, now vaping, smokers wanting to encourage smokers to do what they have done. The early data on e-cigarettes show them to be as good as, or marginally better than nicotine replacement therapy in helping smokers to stop. Which is sad to say that so far, they are about as unsuccessful as NRT for the great majority who use them. Hopefully, better and stronger data will emerge about newer innovations, but until then, their smoking cessation breakthrough status remains hype.
Every smoker who quits via vaping counts on one side of the public health ledger as a success. But as shown in my last blog, the 80% of vapers who only reduce smoking cannot be so counted. Cigarette sales were down 6.2% in France in 2013, while e-cig sales were heralded by vaping advocates as “skyrocketing.” Some of this would have been from quitting, but more would have been from clinically insignificant reduction among continuing smokers. Prospective studies need to examine whether vaping uptake serves to hold a significant number of smokers in smoking, who would otherwise quit, not just immediately, but soon enough to substantially reduce their risk of premature death and serious disease. Such an effect would need to be balanced against the quitting volume achieved in any calculation of net population benefit.
And that’s before we come to questions of the ambitions of e-cigarette manufacturers in all this. All tobacco transnationals now have launched or acquired e-cigarettes lines. As they have done this, none has made statements about their goals of actively working to decrease cigarette sales. And tellingly, none has desisted from aggressively opposing effective tobacco control policy.
Only the most naïve or captured advocates for vaping could fail to acknowledge that the tobacco industry wants people who vape to smoke and vape, not vape instead of smoking. To the credit of some such advocates, nascent policy proposals to accelerate the decline of smoking and calls for governments to set dates for combustible tobacco to be “phased out” have been made. But to date, no government has even gestured serious intent about this beyond sloganeering.
Big Tobacco has already started buying out e-cigarette minnows, and shutting out competition via patent law actions. Here it is following its global playbook in buying up almost all national tobacco companies. Many e-cigarette start-ups would be salivating at the prospect of getting rich quick, but what will be the public health focus of this entirely predictable momentum?
Big Tobacco must think all its Christmases have come at once. E-cigarettes may allow it to profit from nicotine addiction around the clock: in places when you can’t smoke, you should be able to vape, it argues. Restrained from using flavours in cigarettes in some nations, e-cigs offer a cornucopia of kiddie-friendly flavours familiar at pre-schoolers’ birthday parties. With tobacco advertising banned, e-cigarettes have opened the door to all the old themes and allowed the fully market researched semiotics of smoking to be reborn. Those arguing that there will not be any major collateral benefits in this for tobacco companies via smoking are indubitably myopic.
In an inglorious triumph for the logic of capitalism, e-cigarettes also promise hope of respectability to tobacco companies. The same tobacco company staff who scheme to attack effective tobacco control, and bust open low income, high illiteracy markets with cigarette promotions, suddenly have opportunities to present themselves in wolf-in-sheep’s clothing pantomime mode as the solution to the “terrible” health problems that arise because of their work.
Disturbingly, some experienced tobacco control people are now aggressively advocating for the importance of e-cigarettes to be freely advertised to promote wider uptake. For decades the tobacco industry maintained the public farce that they had no interest in children smoking and that their advertising was crafted to attract only smokers, with some magic barrier preventing from attracting the attention of non-smokers and especially children. Privately, they of course understood completely that “The base of our business is the high school student.” (See this powerpoint collection of industry insights into the teenage market)
Yet today, like ventriloquists’ dummies, some e-cigarette advocates blindly insist that the Niagara of advertising like this will have zero impact on non-smoking teenagers and is not “intended” to catch their interest. Big Tobacco cannot believe its luck that it has these people on tap to make the arguments for them.
Early signs are here. In December 2013, the Utah Health Department, in a state with the lowest tobacco use in the country, reported statewide data showing that ever-use of e-cigarettes had doubled in high school kids since 2011, with current use tripling. Seven per cent of grade 10 students were current users. Nearly one third of these reported that they had never smoked cigarettes.
Nations with advanced tobacco control programmes have achieved all time lows with youth smoking. In Australia today only 2.5% of 12-17 year olds smoke daily (p24). None that age has ever seen a domestic tobacco advertisement. This reduction is slowly starving the tobacco industry as fewer people than ever start smoking. But in the name of accommodating the pleas of what are frequently exaggerated claims about the size of the smoking population who “cannot” quit, some policy approaches to e-cigarettes place these amazingly important gains at risk.
London addiction specialist Robert West thinks any nation banning e-cigarettes is “nuts.” But there are many sensible things that be done without banning them, as several nations (eg Singapore) have done.
Smokers desperate to quit tobacco, and unhappy with or uninterested in NRT and prescription cessation products, should be able to access e-cigarettes at pharmacies, perhaps with a permit or prescription. Nearly every nation has such a system of controlled access to drugs with abuse or dependency potential. Only two nations, the USA and New Zealand, allow direct to consumer advertising of prescribed or restricted drugs. No one but those with commercial interests and extremist advocates argue that it is a sensible idea to attract children into addiction.
Scheduling e-cigarettes would allow them to be overseen for quality and safety, carefully monitored through research, and their availability relaxed or tightened on the basis of evidence or benefits or harms. Nicotine is a rapidly and strongly addictive drug, that many find extremely difficult to quit. Every imaginable mistake was made with the way tobacco was sold and marketed. If we are not to repeat those mistakes with a product that so far has an unimpressive record in doing what its advocates claim for it, which threatens to renormalize the smoking performance and hold many smokers longer in their addiction, early caution is critical.
- Simon Chapman on e-cigarettes: the best and the worst case scenarios for public health
- Simon Chapman: Will vapers really “quit and (not) die?”
- Promotion of electronic cigarettes: tobacco marketing reinvented?
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.