Electronic cigarettes: a major controversy in public health

Abstract

The controversies about electronic cigarettes (EC) or electronic nicotine delivery devices (ENDS) have become greater and more complex with the rapid increase in EC without nicotine (ECON). ECON is not a tobacco product but ECON use is considered as smoking.

The first controversy is whether ENDS is efficacious for smoking cessation or reduction. The question can be answered by randomized controlled trials (RCTs) comparing ENDS with placebo, nicotine replacement therapy (NRT) or medications on smokers with quit intention. Emerging evidence from RCT is likely to show some cessation efficacy. However, it would not resolve the related controversy about ENDS promotion as a smoking cessation aid. At the population level, studies have shown that ENDS use is not related to smoking cessation or is negatively associated with quitting. The main concern is that ENDS may delay or prevent smokers from total abstinence and deterring the use of proven-effective cessation treatments including counselling.

The second controversy is about harm reduction. ENDS deliver less chemicals and carcinogens than cigarettes. ENDS may be a “healthier” alternative if smokers replace cigarettes with ENDS and the nicotine intake remains the same. People against ENDS say that ENDS cannot replace cigarettes at the population level, and are against the marketing message and strategies of “harm reduction”. Studies have reported high dual use rates. Most smokers do not switch from cigarettes to ENDS completely, but use ENDS in smokefree environments to circumvent smokefree laws. ENDS marketing with minimal regulations will lead to more problems before realizing the benefits from “harm reduction”. One problem is the rapid increase in ENDS use worldwide. This re-normalization of smoking behavior may lead to increased cigarette smoking in never smokers and reduced smoking cessation in current smokers.

The third controversy is to what extent ENDS should be regulated. A total ban includes banning of manufacture, trade (import and export), sale and purchase, possession and use of ENDS. Most governments are facing challenges and conflicting views from tobacco control advocates, public health professionals, the tobacco and ENDS and related industry and the public.

The fourth and certainly not the least is about ECON, which are being heavily promoted especially if there is a loophole in the law. ECON with numerous flavors and fashionable designs are claimed to be safe. ECON promotions are similar to cigarette marketing in the pre-ad ban era, targeting young people and smokers with health concerns. The safety and long-term health effects of ECON use is uncertain. Apart from the harmful chemicals detected from ECON, the composition of the smoke being inhaled or released into the environment is mostly unknown and highly variable.

What are NOT controversial are that (1) the ENDS and ECON industry is expanding and the Big Tobacco companies have involved in the ENDS business; (2) the debate about ENDS continues among tobacco control advocates and others; (3) Our understanding of the dynamic situations and future trends is grossly inadequate; and (4) much more monitoring and surveillance, research and evaluation are warranted.