The World Health Organisation has just released a report on electronic nicotine delivery systems that calls for their global regulation in the interests of public health. The most well-known such devices are electronic cigarettes or e-cigarettes, which are currently banned in Australia.
In this Viewpoints, Wayne Hall calls for the ban to be lifted, while Ross MacKenzie presents the case for retaining it.
Wayne Hall: Australia has banned the sale of a potentially less harmful way of obtaining nicotine while allowing the most dangerous form – cigarettes – to continue to be sold in convenience stores.
Vapour from electronic delivery systems, or e-cigarettes as they’re popularly known, has been shown to contain fewer carcinogens and less particulate matter than smoked cigarettes.
E-cigarettes have been shown in a randomised controlled trial to have similar efficacy to nicotine replacement products when used as a quitting aid. They may also prove to be a safer longer-term alternative to smoking.
The ban on their sales should be lifted to allow research on the possible public health benefits of these products. But as today’s WHO report says, their sale must be regulated.
They should be sold under tighter restrictions than apply to tobacco until better data are available on their safety and efficacy. And only a limited number of sellers and suppliers should be licensed to sell approved products, allowing for control over quality and safety.
What’s more, all media marketing should be banned to prevent their promotion to children and adolescents.
E-cigarette users should receive product information that clearly explains the uncertainty about their long-term health effects. This would encourage their use for quitting smoking and discourage dual use, that is, using e-cigarettes while continuing to smoke cigarettes.
The sales ban in Australia leaves product quality, marketing, product information and sales to the black market.
Suppliers should be obliged to facilitate research that answers questions essential in developing policy, such as:
• who uses e-cigarettes and for how long;
• how many use them to quit smoking, as a complete substitute for smoking, or only when (and where) smoking is prohibited; and
• how does regular e-cigarette use, alone or in combination with cigarettes, affect the health of users over time.
If e-cigarettes fail to reduce tobacco harm-related harm, as their critics predict, then the sooner we discover this, the better. Meanwhile, we should lift the ban to enable us to properly evaluate their possible value.
Ross MacKenzie: Supporters claim that e-cigarettes represent an important advance in harm reduction and are an effective means of quitting smoking, despite a near-complete absence of research into these claims, or into their safety.
There is a growing body of literature on health risks linked to nicotine, the key component of e-cigarettes. These include head and neck, liver and kidney cancer, among others, as well as impacts on the lung and vascular systems that can have implications for those exposed to tuberculosis.
Given these concerns, and nicotine’s well-established addictive properties, it seems an unlikely substance to position at the centre of harm-reduction or smoking-cessation strategies.
The greatest threat to public health associated with e-cigarettes, however, is the entry of the tobacco industry into the market, as the WHO report notes.
This, coupled with regulatory uncertainty in some countries, has enabled leading cigarette manufacturers such as British American Tobacco, Lorillard, Reynolds American and Altria to aggressively promote electronic products that are designed and packaged to look remarkably like traditional cigarettes.
In the United States, e-cigarette advertisements have been accused of targeting adolescents and children, millions of whom have been exposed to advertisements on television and other media.
Resolution of the current debate has enormous consequences for public health. If not regulated as traditional cigarettes, the promotion of e-cigarettes has the very real potential to re-normalise smoking, undoing decades of progress in tobacco control, which has led to declining smoking prevalence in many countries.
At this point, the risks associated with e-cigarettes far outweigh any ostensible benefit.
Wayne Hall: The dogmatic certainty of those who support e-cigarette sales bans is remarkable given their claim that we lack any evidence on the safety of these products.
They already claim to know that the risks will outweigh the benefits. And they want to insulate their beliefs against being tested by advocating for a ban.
This will make it difficult to discover if anything except tobacco industry-owned e-cigarettes are effective cessation aids. And it will make it even more difficult to discover if they are a safer way of obtaining nicotine in the long term than cigarettes.
While I support the regulation of e-cigarettes as tobacco products, that’s not the policy we have in Australia. Instead, our policy absurdly treats e-cigarettes like illicit drugs: it prohibits their sale and prevents smokers from using them except by black market purchases.
I share the concerns of the WHO and the public health community about tobacco industry involvement in the e-cigarettes business. But I believe these concerns are better addressed by regulation than a prohibition supported by dogmatic claims that undermine the public health community’s assertion to pursue evidence-based policies.
Ross MacKenzie: Another way of saying that Australia has banned a potentially less harmful way of obtaining nicotine is that a product has been prohibited because its potential health impacts are unknown, and its value as means of harm reduction and cessation unproven.
I agree that cigarettes should not be sold in convenience stores and should be much harder to obtain. This is a policy area that the public health community should be advocating for, rather than bringing another, controversial nicotine-delivery system onto the market.
Calls to regulate e-cigarettes offer little comfort given that the marketing, purchase and use of traditional cigarettes is well-regulated, but smoking still causes some 15,000 deaths every year in Australia.
As for smuggling, that’s a criminal issue to be dealt with by appropriate authorities. Arguing that the ban on e-cigarettes will lead to black market sales is uncomfortably reminiscent of tobacco industry arguments that raising cigarette taxes and plain packaging would lead to increased levels of contraband.
Finally, growing evidence that nicotine is tumour-promoting and linked to at least ten types of cancer makes current lobbying to allow another nicotine-delivery system onto the market a decidedly curious initiative.
Wayne Hall is an investigator on a clinical trial of e-cigarettes for smoking cessation that is funded by the National Health and Medical Research Council. He has no interests in or associations with e-cigarette companies and he does not receive funding from the pharmaceutical industry.
Ross MacKenzie has received funding from the Rockefeller Foundation, and the National Institutes of Health.