A tool to quit smoking, a simple lower-risk consumer product, or a gateway to smoking or nicotine addiction? Celebrated as disruptive tools for quitting smoking, e-cigarettes also face criticism for their potential role in nicotine addiction among non-smokers, especially young people. The debate over e-cigarettes clearly illustrates the broader challenges in public health policy: balancing potential benefits with risks and navigating a complex environment influenced by economic interests, scientific dogmas, and lack of political transparency. But is it a dilemma?
To arrive at a possible answer to the question in the title, scientific evidence must be consistently and appropriately debated, analyzed, and communicated. Although these devices have proven to be significantly less harmful than traditional cigarettes and effective in helping people quit smoking, legitimate concerns persist, often ideologically aggravated, regarding their use among young people and non-smokers.
However, there is a certain consensus that policies and regulations should be based on solid and up-to-date scientific data to balance the promotion of smoking cessation with the prevention of a new wave of nicotine addiction.
The dichotomy between public and scientific opinion demands that the scientific community constantly explore the available evidence. The necessary information can be provided through rigorous and ongoing analysis to policymakers, healthcare providers, and the general public, enabling balanced and effective regulation of these devices.
Since at least the early 2010s, e-cigarettes have garnered attention for their potential to aid in smoking cessation. A study led by Pasquale Caponnetto and Riccardo Polosa, published in 2011, documented the first case in which the outcomes of quitting smoking using e-cigarettes were objectively measured in individuals who had repeatedly failed in their previous attempts despite receiving professional support, using conventional treatments, and participating in intensive counseling.
A robust report presented in 2018 by the National Academies of Sciences, Engineering, and Medicine of the U.S. evaluated the effectiveness of e-cigarettes as a “potentially effective” tool for smoking cessation. It concluded that they are “considerably less harmful” than continuing to smoke conventional tobacco.
The most robust body of evidence ever produced suggests that e-cigarettes are more effective than traditional nicotine replacement therapies. The 2024 Cochrane systematic review, which examined 88 studies, concluded that vaping nicotine is 59% more effective for quitting smoking than nicotine patches and gum. Similarly, a review by the UK’s National Institute for Health Research identified vaping as the most effective individual aid for smoking cessation currently available.
Scientists advocating for the Gateway Out Effect, or Displacement, firmly believe that the mechanism by which e-cigarettes facilitate smoking cessation is multifaceted. These devices provide a familiar behavioral and sensory experience for smokers, which is crucial for those struggling to quit. Additionally, the ability to try many pleasant flavors and aromas aids in the transition away from combustible cigarettes.
Furthermore, e-cigarettes allow many users to reduce their nicotine consumption gradually. This process, known as nicotine titration, helps users effectively manage their nicotine intake.
On the other hand, scientists who are predominantly staunch advocates of Tobacco Control are also inflexible proponents of the Gateway Hypothesis and seem convinced that the rising prevalence of e-cigarette use has led to a resurgence in smoking.
Critics of safer nicotine products argue that e-cigarettes serve as a gateway to smoking, potentially reversing decades of progress in tobacco control. However, the evidence supporting this gateway hypothesis is even more contentious than the Displacement Hypothesis and is often methodologically flawed.
The confusion in the definition of use
A systematic review and meta-analysis conducted by scientists from the Canadian company Thera-Business examined the association between e-cigarette use among non-smokers and the initiation of combustible cigarette smoking.
The review included 55 studies and found an association between non-regular e-cigarette use and the initiation of smoking, with an adjusted odds ratio (OR) of 3.71. This means that, after controlling for other factors that could influence the results, the likelihood of starting smoking is approximately 3.71 times higher in the group that uses e-cigarettes compared to the group that does not use them.
However, the review also highlighted several methodological limitations, including inconsistent definitions of “use” and inadequate control of confounding variables. Most studies used a broad definition of e-cigarette use, often conflating experimentation with regular use. For example, many studies classified individuals as e-cigarette users if they had tried an e-cigarette just once, thus inflating the perceived risk of progression to regular smoking.
Moreover, the majority of young people who experiment with e-cigarettes do not continue using them regularly, suggesting that experimentation does not necessarily lead to sustained use or subsequent smoking.
Political Implications and the Need for Balanced Regulation
The debate over e-cigarettes focuses on individual health impacts and broader political implications. Effective regulation must balance the potential benefits of e-cigarettes as a harm-reduction tool with the need to protect young people from nicotine addiction.
A significant challenge in regulation is the unintended consequences of policies presented to the public as well-intentioned. For example, flavor bans aimed at reducing appeal to young people may inadvertently lead adult users back to smoking or illicit market products without any quality control.
A study on flavor bans in San Francisco found that smoking increased among high school students following the ban’s implementation. This outcome exemplifies and underscores the importance of considering all potential impacts of policies, including those that may be counterproductive.
The economic implications of excessively taxing risk and harm-reduction products must be carefully evaluated. In the case of smoking, evidence suggests that e-cigarettes and combustible cigarettes are economic substitutes. Increasing the price of e-cigarettes through high taxes could inevitably lead to an increase in cigarette consumption.
Wouldn’t increasing consumer prices and implementing prohibitionist and overly restrictive policies be a proper Gateway to or Return to smoking?
Another study estimated that a proposed national tax on e-cigarettes in the U.S. would increase the proportion of daily smokers by approximately one percentage point, translating to 2.5 million additional daily smokers.
The research, conducted by experts from institutions such as Georgia State University and the University of Kentucky, highlighted that taxing e-cigarettes at $1.65 per milliliter of vaping liquid would lead more adults to switch from vaping to smoking cigarettes, which are more harmful to health.
One of the lessons provided by science is that a risk-proportional approach is essential to address the complexities of e-cigarette regulation and move towards Evidence-Based Regulation. This approach recognizes the significant harm reduction provided by smokeless nicotine products compared to combustible cigarettes.
The state has a duty to regulate and limit markets in the community’s best interest. In this regard, it must ensure that regulatory measures focus on guaranteeing the quality and safety of products, providing accurate information to consumers, and preventing access by minors without unduly restricting the ability of adult smokers to switch to less harmful alternatives.
Some Recommendations for Policymakers
Many scientists and health experts have raised essential points for good (necessarily balanced) regulation. First, it is crucial to keep taxes on e-cigarettes low compared to the high taxes on combustible cigarettes. This strategy will economically incentivize and help smokers switch to less harmful alternatives. Additionally, policies that may make e-cigarettes less accessible or attractive than smoking should be avoided.
Likewise, e-cigarette advertising should be regulated to ensure it is exclusively directed at adult smokers, restricting marketing aimed at minors. The messages, from both a market interest and public health perspective, should emphasize the harm reduction benefits associated with e-cigarette use compared to traditional smoking.
Public authorities should implement rigorous standards regarding product quality and safety, including limits on potentially harmful products and chemicals and robust testing requirements. Ensuring products are manufactured to high-quality standards will minimize health risks to consumers.
Additionally, in the realm of commerce, strict age verification processes should be applied to prevent minors from accessing e-cigarettes. Furthermore, educational campaigns that inform young people and their guardians about the risks of nicotine use without confusing the relative risks of smoking and vaping are essential.
Finally, it is crucial to establish comprehensive surveillance systems to monitor trends in e-cigarette use, their health impacts, and the effectiveness of regulatory measures. Policies should be continuously adjusted based on emerging scientific evidence and rigorous data analysis.
Towards Informed Regulation to Maximize Benefits and Minimize Risks
The debate over e-cigarettes exemplifies the broader challenges in public health policy: balancing potential benefits with risks and navigating a complex landscape influenced by economic interests, scientific dogmas, and political opacity.
Although e-cigarettes are not without risks, the current body of scientific evidence, exemplified by the Cochrane review, strongly supports their role in harm reduction for smokers. Policymakers can adopt a nuanced approach that mitigates risks for non-smokers while leveraging the potential of e-cigarettes to reduce the burden of smoking-related diseases significantly.
As the public debate is expected to mature, it is imperative to base policy decisions on robust scientific evidence, recognize the limitations of existing studies, and be open to adjusting policies as new data emerge. By doing so, the benefits for public health can be maximized and unintended harms minimized, ultimately contributing to a healthier society.