Addiction? The Public Health Impact of E-cigarettes

The Society For The Study Of Addiction has released a study titled “A framework for evaluating the public health impact of e-cigarettes and other vaporized nicotine products” which contains the following conclusions:

• In the US, increasing e-cigarette use has been accompanied by an unusually large reduction in adult and youth smoking prevalence.
• These products expose users to substantially lower levels of toxicants than combustible cigarettes.
• A multi-criteria decision analysis estimated that exclusive VNP use is associated with 5% of the mortality risks of smoking. This is comparable to the estimated risks of low-nitrosamine smokeless tobacco.
• Studies using major biomarkers of cancer and other chemicals in e-cigarettes indicate substantially lower (e.g. 9–450 times) levels compared to cigarette smoke.
• For dual users, VNP use may translate to a lower quantity and duration of cigarettes smoked. Both may decrease lung cancer and chronic obstructive pulmonary disease (COPD) risk.
• The potential to reduce risk is likely to depend upon the age of initial dual use. Although much use now begins at later ages, VNP use is likely to occur at earlier ages in more recent cohorts of smokers, and thereby provide a greater reduction in cigarette use and toxic exposures over longer periods of use.
• Initiating VNP use before cigarette smoking may delay or prevent smoking initiation and thereby reduce smoking risks.
• The population health impact depends critically upon whether the never smoker who tries VNPs would have smoked cigarettes in the absence of VNPs.
• Studies of youth and young adult use from the United States and other countries using different use measures have found current smokers to be at least 15 times more likely to use VNPs than never smokers.
• Adolescents and young adults who use VNPs are most likely to be those at higher risk of initiating cigarette smoking.
• Young VNP experimenters are more likely to engage in other risky behaviors and have executive function deficits like those found in cigarette smokers. These findings suggest that a common liability model is more plausible than a gateway from VNP use to cigarette smoking.
• Because VNPs are more widely available and often more appealing to smokers than conventional NRT, they have the potential for having a larger impact on the rate of smoking cessation in the population.
• Concerns have been raised that cigarette smoking will be re-normalized by VNP use. This issue can be addressed by the media and public health campaigns that encourage norms that are hostile to cigarette smoking and at the same time distinguishing clearly between VNP and cigarette risks, discouraging dual use and encouraging exclusive VNP use.
• The availability of VNPs may provide a justification for stronger policies to discourage cigarette smoking because smokers, particularly those of lower socio-economic status and with mental health issues, are given a less risky and potentially less costly alternative way to service their need for nicotine.
• Cigarette companies that have entered the smokeless tobacco market have encouraged dual rather than exclusive use, and are likely to do the same with VNPs. By contrast, VNP companies that are unaffiliated with cigarette manufacturers want smokers to switch completely from cigarettes to VNPs.
• Product content regulations that create regulatory hurdles that only large firms can surmount are likely to favor the cigarette industry and discourage innovation by firms outside the cigarette industry.
• Cigarette companies do not control VNPs as they do the rest of the tobacco business; many manufacturers of e-cigarettes such as NJOY do not sell cigarettes, and there are thousands of vape shops that are independent of the cigarette industry
• Retailer point-of-sale restrictions, which limit subsidies by cigarette manufacturers to provide shelf space and price promotions, can reduce price discounting and discourage advertisement displays. This could provide greater shelf space for VNP products to be sold by independent firms.
• From a public health perspective, VNP policies should aim to discourage experimental and regular use of VNPs by never smokers who would not have smoked otherwise while encouraging innovations in VNP products that promote smoking cessation. The evidence suggests a strong potential for VNP use to improve population health by reducing or displacing cigarette use in countries where cigarette prevalence is high and smokers are interested in quitting.
• The primary aim of tobacco control policy should therefore be to discourage cigarette use while providing the means for smokers to more easily quit smoking, even if that means switching for some time to VNPs rather than quitting all nicotine use.

The use of vaporized nicotine products (VNPs), especially e-cigarettes and, to a lesser extent, pressurized aerosol nicotine products and heat-not-burn tobacco products, are being adopted increasingly as an alternative to smoking combusted products, primarily cigarettes. Considerable controversy has accompanied their marketing and use. We propose a framework that describes and incorporates patterns of VNP and combustible cigarette use in determining the total amount of toxic exposure effects on population health. We begin by considering toxicity and the outcomes relevant to population health. We then present the framework and define different measures of VNP use; namely, trial and long-term use for exclusive cigarette smokers, exclusive VNP and dual (cigarette and VNP) use. Using a systems thinking framework and decision theory we considered potential pathways for current, former and never users of VNPs. We then consider the evidence to date and the probable impacts of VNP use on public health, the potential effects of different policy approaches and the possible influence of the tobacco industry on VNP and cigarette use.

Stefan Didak

Stefan Didak is the founder and president of NOT Blowing Smoke. Prior to dedicating all his time to vaping advocacy he was a software engineer who started his first business at the age of 18 and for over 25 years was involved in developing 3D computer graphics and animation software. Stefan has been featured in many articles and interviews on the subject of vapor products, including professor Stanton Glantz’ Tobacco Control blog at the University of California, San Francisco.