Are electronic cigarettes a tool for quitting smoking, a lower-risk consumer product, or a gateway to smoking or nicotine addiction? Hailed as disruptive tools for quitting smoking, electronic cigarettes also face criticism for their potential role in nicotine addiction among non-smokers, especially young people. This debate clearly illustrates the broader challenges in public health policy: balancing benefits with risks, as well as navigating a complex environment influenced by economic interests, scientific dogmas, and political opacity. But is it really a dilemma?
To answer the question posed in the title, scientific evidence must be debated, analyzed, and communicated consistently and appropriately. Although these devices have proven to be significantly less harmful than traditional cigarettes and effective in helping people quit smoking, concerns about their use among young people and non-smokers persist.
These concerns, while legitimate, are often exaggerated for ideological reasons. Despite this, there is a certain consensus that policies and regulations should be based on solid and updated scientific data to balance the promotion of smoking cessation with the prevention of a new wave of nicotine addiction.
The dichotomy in public and scientific opinion demands constant exploration of the available evidence. Only through rigorous and continuous analysis can the necessary information be provided to policymakers, healthcare providers, and the general public, thus allowing for balanced and effective regulation of these devices.
Since at least 2010, electronic cigarettes have received 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 where the outcomes of quitting smoking using electronic cigarettes were objectively measured in individuals who had repeatedly failed in their previous attempts despite professional support, conventional treatments, and intensive counseling.
A robust report presented in 2018 by the U.S. National Academies of Sciences, Engineering, and Medicine evaluated the effectiveness of electronic 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 suggests that electronic 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 in 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 quitting smoking available today.
Scientists who support the “gateway out” or “displacement” effect are convinced that the mechanism by which electronic 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 smoking. Additionally, trying many pleasant flavors and aromas facilitates the transition from combustible cigarettes.
Moreover, electronic cigarettes allow many users to reduce their nicotine intake gradually. This process, known as nicotine titration, helps users effectively control their intake of this substance.
Scientists, most of whom are staunch advocates of tobacco control, also firmly support the “gateway” paradigm and seem convinced that the increasing prevalence of electronic cigarette use has led to a resurgence in smoking.
Critics of safer nicotine products argue that electronic cigarettes serve as a gateway to smoking and can reverse decades of progress in tobacco control. However, the evidence supporting this hypothesis is even more controversial than that of “displacement” and often methodologically flawed.
Confusing Definitions
A systematic review and meta-analysis conducted by scientists from the Canadian company Thera-Business examined the association between the use of electronic cigarettes among non-smokers and the initiation of combustible cigarette use.
The review included 55 studies and found an association between non-regular use of electronic cigarettes and smoking initiation with an adjusted odds ratio (OR) of 3.71. This means that, after controlling for other factors that could influence the outcomes, the likelihood of initiating smoking is approximately 3.71 times higher in the group that uses electronic cigarettes compared to the group that does not.
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 electronic cigarette use, often confusing experimentation with regular use.
For example, many studies classified individuals as electronic cigarette users if they had tried an electronic cigarette just once, thus inflating the perceived risk of progression to regular smoking.
Additionally, most young people who experiment with electronic cigarettes do not continue using them regularly, suggesting that experimentation does not necessarily lead to sustained use or subsequent smoking.
Policy Implications: Balanced Regulation Needed
The debate over electronic cigarettes addresses the impact of electronic cigarettes on individual health and broader political implications. Effective regulation must balance the potential benefits of electronic cigarettes as a harm-reduction tool with the need to protect young people from nicotine addiction.
A major challenge in regulation is the unintended consequences of policies presented to the public as well-intentioned. For example, flavor bans, intended to reduce the appeal to young people, may inadvertently drive 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 possible impacts of policies, including those that may be counterproductive.
Furthermore, the economic implications of excessively taxing risk and harm-reduction products must be carefully evaluated. In the case of smoking, evidence suggests that electronic cigarettes and combustible cigarettes are economic substitutes. Raising the price of electronic cigarettes with high taxes could lead to an increase in cigarette consumption.
Are There Other “Gateways”?
Another study estimated that a proposed national tax in the U.S. on electronic cigarettes would increase the proportion of daily smokers by approximately one percentage point, translating to 2.5 million additional daily smokers.
Research conducted by experts from institutions such as Georgia State University and the University of Kentucky highlighted that taxing electronic cigarettes at $1.65 per milliliter of vaping liquid would cause more adults to switch from vaping to smoking cigarettes, which are more harmful to health.
One of the lessons provided by science is that addressing the complexities of electronic cigarette regulation and moving towards evidence-based regulation requires a risk-proportional approach.
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 to favor collective interests. In this sense, it must ensure that regulations focus on guaranteeing product quality and safety, providing accurate information to consumers, and preventing minors’ access without unduly restricting adult smokers’ ability to switch to less harmful alternatives.
If the above is not ensured, measures such as increasing consumer prices and overly restrictive policies could become a true gateway—or return—to smoking.
Some Recommendations for Policymakers
Many scientists and health experts have raised essential points for balanced regulation.
First, keeping taxes on electronic cigarettes low while imposing high taxes on combustible cigarettes is crucial. This strategy will incentivize and economically help smokers switch to less harmful alternatives. Additionally, policies that could make electronic cigarettes less accessible or attractive than smoking should be avoided.
Electronic cigarette advertising should be regulated to ensure it is directed exclusively at adult smokers, restricting marketing to minors. Messages, from both market interest and public health perspectives, should emphasize the harm reduction benefits associated with using electronic cigarettes compared to traditional smoking.
Public authorities must implement rigorous standards regarding product quality and safety, including limits on potentially harmful substances and robust testing requirements. Ensuring products are manufactured to high-quality standards will minimize health risks for consumers.
Additionally, in the field of commerce, strict age verification processes should be applied to prevent minors from accessing electronic cigarettes. Furthermore, it is important to consider educational campaigns that inform young people and their guardians about the risks of nicotine use without confusing the relative risks of smoking and vaping.
Finally, it is essential to establish comprehensive surveillance systems to monitor electronic cigarette use trends, their health impact, and the effectiveness of regulatory measures. Policies should be continuously adjusted based on emerging scientific evidence and rigorous data analysis.
Informed Regulation for More Benefits and Fewer Risks
The debate on electronic cigarettes exemplifies the 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 electronic cigarettes are not without risks, the current body of scientific evidence, as 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 electronic cigarettes to reduce the burden of smoking-related diseases significantly.
As the public debate matures, it is imperative to base policy decisions on robust scientific evidence, recognize the limitations of existing studies, and remain open to adjusting policies as new data emerge.
By doing so, we can maximize public health benefits and minimize unintended harms, ultimately contributing to a healthier society.