Can e-cigarettes be a public health victory?

Annoying mall vendors have been pushing what may be one of public health’s greatest accomplishments—and few have taken notice. Behind pillow pet stations and the candle stand, mall shoppers can find electronic cigarettes, or “vapes.” Often targeted at smokers wanting to quit, e-cigarettes offer many of the joys of smoking without one of its major components: smoke.

Smokeless cigarettes have become a hot product, with an estimated $1.7 billion in sales this year.  According to a recent article in the Journal of the American Medical Association, over 10% of smokers have tried e-cigarettes, and almost 5% have used them in the past month. Often marketed as smoking-cessation products, a small Italian study suggested that smokers do smoke fewer real cigarettes when given e-cigarettes.  A 2011 study in Addiction found that 77% of users used e-cigarettes for the purpose of smoking cessation and that 79% of users were afraid of relapse if they stopped using the e-cigarette. Their efficacy as a smoking cessation tool is still in question.

But for e-cigarettes to be a successful public health intervention, they do no not need to help smokers quit.

E-cigarettes need not be just a smoking cessation tool. Instead, their potential comes as a smoking maintenance tool that could greatly reduce individual and public health risks. Unlike other nicotine replacement therapies such as the patch or gum, e-cigarettes deliver the full smoking experience: as users put cigarettes to their lips, see a light when they inhale, and even receive a smoke-like “throat hit.”

Studies have not yet shown that e-cigarettes are healthier than tobacco cigarettes, since longitudinal studies of this kind are years down the line. But e-cigarettes lack the major carcinogens in tobacco cigarettes, which come not from nicotine but from other toxins. Most e-cigarettes use liquid cartridges with very few ingredients: water, nicotine, flavoring, and propylene glycol. Should these cartridges be shown to have toxic effects, they are likely to be orders of magnitude less severe than those of traditional tobacco cigarettes.

E-cigarettes also offer socioeconomic benefits. They can be much cheaper than traditional cigarettes: a “5 pack” of e-cigarette cartridges costs $10 compared to the $36 for 5 packs of tobacco cigarettes. As tobacco smoking is more common among disadvantaged groups with lower income and wealth, decreasing the cost of the habit could help less wealthy individuals and families.

Greater still are the societal implications of e-cigarettes. Widespread adoption of e-cigarettes—even without a decrease in nicotine intake—would create more smoke-free spaces and communities, reducing the negative health consequences of second-hand smoke. “Third-hand smoke,” a newly coined term for carcinogen deposits on clothes and furniture, which has been reported to be even more dangerous than second-hand smoke, could disappear before most people hear of it.

There are still good arguments against e-cigarettes: “secondhand vapor” of propylene glycol might still irritate others, short-term use of e-cigarettes can increase airway resistance, nicotine increases blood pressure, and e-cigarettes may introduce some non-smokers to an addictive behavior they would have otherwise avoided, especially teens.

E-cigarettes could soon become harder to acquire or more expensive, as FDA regulations this fall may ban Internet sales or otherwise restrict their sale and marketing. But even when accepting the potential individual health risks, electronic cigarettes have the potential to greatly reduce one of the world’s greatest public health risks.

E-cigarettes will be a major research topic in the years ahead. But instead of seeing them as a smoking cessation tool, we should see their potential as a safer smoking maintenance option. Reducing individual health risks and, more importantly, potentially eliminating the societal health risks of second- and third-hand smoke makes you think: those annoying mall vendors may be saving lives.

Justin Berk is a medical student. 

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  • May Wright

    “FDA regulations this fall may ban Internet sales or otherwise restrict their sale and marketing.”

    I don’t understand what the point of this is. I know several people who’ve switched from tobacco cigarettes to these things, and that strikes me as nothing but a good thing. Why would the FDA want to make them harder to get and more expensive? Cui bono?

  • Preston Gorman

    I think that the point is to keep this from becoming epidemic with teens. However, I think that the potential public health benefits should be considered when regulating these things. Sales avenues should be at least as liberal as tobacco cigarettes.

    • May Wright

      The figures provided in the link in this article show that with the way e-cigs are currently marketed, priced and sold, 3.5% of high school students had used one at least once during the past thirty days.

      Figures from the CDC show that with the way tobacco cigarettes are currently marketed, priced, and sold, 18.1% of high school students had smoked at least one during the past thirty days.

      It looks like no matter how many restriction the federal government lays down, they’re not very good at keeping kids from breaking the law and ingesting things they shouldn’t.

      I’m pretty sure all they’ll do is make e-cigs more expensive and harder to get for adult smokers (especially those with lower incomes) who could actually benefit from switching to them.

      • Preston Gorman

        Well said. There is probably a long list of cigarette manufacturers lobbying for the regulation of their new competition.

  • Mike Schueler

    As a family physician, I have deep reservations about e cigarettes. Most of my patients get the most harm from the nicotine in smoking, not the carcinogens. It is nicotine that causes the rapid progression of CAD and peripheral vascular disease, which is a bigger killer and cause of morbidity than lung cancer, which is not as common and more rapidly fatal. We can keep smokers with vascular disease alive a surprisingly long time.

    Perhaps there might be less emphysema with these, but there really isn’t any research out there to indicate that these things are “better”, less apt to cause lung damage. And there likely won’t be for a while, if someone decides to pay for that research. This means that they can be marketed as safe, even though they aren’t really proven to be so, because they fall into a legal loop hole.

    So the good part of e cigarettes? Maybe less carcinogenic, but this isn’t certain. Maybe less emphysema, this isn’t certain.

    Cheaper yes, and not regulated.

    To me those are big step backwards for public health.

    • Guest

      “Most of my patients get the most harm from the nicotine in smoking, not
      the carcinogens. It is nicotine that causes the rapid progression of
      CAD and peripheral vascular disease, which is a bigger killer and cause
      of morbidity than lung cancer”

      Really?

      So how’s your jihad against nicotine gum, mints and patches going?

    • Bryan Chandler

      You seem to be letting the perfect be the enemy of the good.

  • KJK

    This is a very interesting article Its nice to see this perspective, as a pharmacist one of the major things we often recommend to our patients is to quit smoking. I am very interested to see where the research takes this recommendation.

  • Bryan Chandler

    But how can the gum & patches which you say your patients, “generally don’t use those for the long term because of cost, skin irritation, yucky taste.” be effective smoking cessation products? You yourself said they sometimes help get them off tobacco. From my personal experience (which isn’t a peer-reviewed study of course) e-cigs have an much higher success rate.
    The e-cig community is very eager to have true, peer-reviewed studies done in order for the facts to be known about e-liquids.This of course takes time. And even the few preliminary studies that have been done show virtually no toxic effects. I’ll refer you CASSA http://casaa.org/ for more information on these studies.
    My point is, just because something is not “harmless” in the strictest use of the word doesn’t mean it’s benefits far out-weigh the risks, i.e. continued tobacco use. It’s the only way I was able to quit, and very many others I know have quit 100%.