e-Cigarettes: More Good Than Harm?

Liam Davenport

April 27, 2016

Rather than viewing e-cigarettes as a "gateway" to smoking, their potential for significant harm reduction should be acknowledged and taken into account when developing policies to control their use, experts say.

They write that the primary aim of tobacco control policy should be to discourage cigarette use while providing the means for smokers to quit more easily, "even if that means switching for some time to VNPs [vaporized nicotine products] rather than quitting all nicotine use."

They add: "As we gain clearer knowledge of the effects of cigarette- and VNP-oriented policies, a long-term view that reduces the use of the most toxic combusted tobacco nicotine delivery products will become a more realistic goal."

To those ends, and to help formulate tobacco control policy, they devised a series of frameworks for assessing the possible impact of both short-term and long-term use of e-cigarettes in never-smokers, current smokers, and former smokers.

Nevertheless, lead author David T. Levy, PhD, professor, Department of Oncology, Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, told Medscape Medical News that "there is no magic way to regulate."

He said that this is a "complex problem" and that he and his colleagues tried "to provide a framework for analyzing that problem, looking at the potential harms as well as the potential benefits.

"If regulators use that framework or something similar, I think they'll at least move in the right direction."

The article was published online April 25 in Addiction.

Lower Mortality Risk

The authors cited recent research that suggests that e-cigarettes are associated with 5% of the mortality risks related to smoking. There are a number of e-cigarette devices on the market, and they are evolving rapidly.

The authors also note that dual use of e-cigarettes and conventional cigarettes may lead to substantial reductions in the quantity and duration of cigarettes smoked, thus decreasing the risk for lung cancer and chronic obstructive pulmonary disease.

Starting to use e-cigarettes before smoking conventional cigarettes may also, they note, delay or prevent smoking initiation in those who would otherwise have smoked. "If, however, VNP use encourages the long-term use of cigarettes, or VNPs are used by those who would not have otherwise smoked, the net societal benefit would be diminished and VNPs could incur population-level harm," they write.

In 2014, the US Food and Drug Administration (FDA) proposed a law that would extend the agency's authority to regulate additional products that meet the legal definition of a tobacco product, such as e-cigarettes.

However, the authors note that before imposing regulations, the FDA "must consider scientific evidence" on the individual- and population-level benefits and harms of the devices.

They offer a novel method for evaluating the public health impact of e-cigarettes, centered on three frameworks for determining the effects of short-term, transitional, and long-term use of the devices in never-smokers, current smokers, and former smokers.

In each case, they weigh the impact of e-cigarettes in terms of whether they would be harm reducing, harm reducing in the context of reductions in the quantity of cigarettes smoked, and harm increasing.

For never-smokers, they suggest, for example, that e-cigarettes would be harm increasing if e-cigarettes were used long term in people who would not have become smokers in the absence of e- cigarettes.

Harm Reduction

In contrast, they would be harm reducing over the long term in those who would have smoked cigarettes in any case, although that benefit would be questionable in the case of persons who become long-term dual users of cigarettes and e-cigarettes.

Dr Levy pointed out that although the notion of e-cigarettes being safe and thus becoming normalized could have unintended consequences, cigarettes "are likely to be much, much more dangerous than e-cigarettes.

"So if we can get people to quit smoking cigarettes and switch to e-cigarettes, on balance, there'll be a public health gain."

Measures affecting the availability of both e-cigarettes and conventional cigarettes are needed to achieve that. Dr Levy said: "I think it's going to be important for us to monitor e-cigarette use at younger ages and implement policies to discourage that use, such as not allowing their sale below a certain age.

"But even more important is to raise the age for cigarettes. If we raise the age for e-cigarettes but not for cigarettes, then we might encourage smoking."

Dr Levy also believes that further regulation of the advertising of tobacco products is required, including banning advertisements at the point of sale, placing strong health warnings on cigarette packages, and continuing to increase taxes on tobacco products.

Opposition from the tobacco industry could pose a hurdle to implementing those measures. "In the United States, we've seen how the cigarette industry fights things," Dr Levy said. "We were supposed to have the health warnings on cigarettes. We didn't have them.

"We need to be careful that the cigarette companies don't gain control of the e-cigarette market. We need regulations to allow some degree of competition in that industry so it's not dominated by the cigarette manufacturers."

FDA Response

FDA press officer Michael Felberbaum told Medscape Medical News that the agency evaluates studies "as part of a larger body of evidence.

"The agency knows that, though all tobacco products are potentially harmful and potentially addictive, different categories of tobacco products may have the potential for varying effects on public health," he said.

Felberbaum said that the law proposed by the FDA in 2014 will allow the FDA to "consider the potential public health impacts of these products for both users and nonusers.

"When finalized, the rule will represent a significant step in the agency's ability to protect public health and learn more about these products," he added.

A final rule "will also allow us to address product safety issues and educate consumers about risks associated with use, reduce tobacco sales to youth, and prevent misleading health claims," Dr Levy concluded.

Funding was received from the FDA through a grant from the National Institute on Drug Abuse. One coauthor has provided testimony on behalf of plaintiffs in cases against the tobacco industry.

Addiction. Published online April 25, 2016. Abstract

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