Over the past ten years, a substantial minority of cigarette smokers in many countries have turned to electronic (e-) cigarettes in an attempt to quit smoking or as an alternative to smoking some or all of the time. In 2013 around 600,000 Australian smokers had tried e-cigarettes, while there are currently around 2.6 million e-cigarette users in Great Britain.
These devices avoid burning tobacco and don’t produce smoke, tar and particulate matter. Instead they use an electronic system to produce a mist containing nicotine and propylene glycol and/or vegetable glycerine that can be inhaled much like tobacco smoke to deliver nicotine to the lungs.
E-cigarettes deliver much lower levels of toxins and carcinogens than cigarettes, and are 95% less harmful than cigarettes according to some proponents.
But Australia has banned the sale of e-cigarettes containing nicotine. Nicotine can only be imported for use in vaporisers on a medical prescription, but a spokesperson for the Royal Australasian College of Physicians would like to ban this too.
As we argue in the recent edition of the journal Addiction, the ban on e-cigarettes is ethically questionable. It’s a paternalistic policy that denies adult smokers the right to use a less harmful form of nicotine.
Banning a less harmful product (e-cigarettes) while allowing the most harmful (tobacco cigarettes) to be freely sold is an incoherent form of risk regulation. It also disadvantages smokers who may have difficulty quitting but want to reduce the risks of smoking.
The ban has resulted in the black market of nicotine over the internet and “under the counter” and prevented any sensible regulation of e-cigarettes to reduce risks to consumers and others, including children.
Supporters of the ban argue it prevents the tobacco industry (which now owns some e-cigarette producers) from undermining smoke-free policies by encouraging smokers to keep smoking and use e-cigarettes only in areas where smoking is prohibited (this is known as dual use).
They argue a ban prevents e-cigarettes from “renormalising” smoking by increasing the public visibility of a behaviour that resembles smoking and limits promotion of e-cigarettes to adolescents and young adults.
Media coverage of the Australian ban often seems to suggest we only have two policy choices: either ban these products, or allow their unfettered and unregulated promotion, as is now happening in the United Kingdom and United States.
We oppose laissez faire policies towards e-cigarettes because they may increase the risks that have motivated the ban – dual use by smokers, uptake by minors, and re-normalising smoking. But there is another more ethically acceptable policy option: allowing e-cigarettes to be sold to smokers, while using tight regulation to minimise adverse outcomes.
We propose allowing adult smokers to buy approved e-cigarette products from a restricted number of licensed sales outlets. Any promotional material for these products could be restricted to information supplied to smokers purchasing these products.
Consumer law could be used to ensure a reasonable level of safety to users and others, such as requiring child-proof containers for nicotine, electrical safety and appropriate labelling. At the point of sale, purchasers would be told:
- to avoid dual use (except as a time-limited path to quitting)
- that quitting all forms of nicotine use is the safest option
- that we do not have definitive evidence on the health effects of using e-cigarettes as a long-term alternative to cigarette smoking.
This approach would facilitate research on the uptake and use of e-cigarettes that is badly needed to inform policy. Regulations could, for example, make reporting sales data and basic user characteristics (age, sex, smoker status) a condition of having a license to sell e-cigarettes.
Researchers could then conduct long-term follow up studies of e-cigarettes users to discover:
- who uses e-cigarettes and for how long
- how many quit smoking, engage in dual use and cease all nicotine use
- the medium-term health effects of dual use and using e-cigarettes alone.
Regulating e-cigarette sales respects smoker autonomy and reduces the inconsistency in preventing smokers from accessing e-cigarettes while allowing them to freely buy cigarettes. It would also provide better consumer protection of e-cigarette users, regulate promotion of these products and probably reduce the black market for e-cigarette products in Australia.
This policy could be readily reversed if e-cigarettes prove to be as disappointing as their critics predict. If e-cigarettes prove to be attractive to most smokers and much safer substitutes for combustible cigarettes, as their advocates claim, then these regulations could be relaxed by increasing the number of outlets allowed to sell them.
We could do this while increasing restrictions on where cigarettes could be sold, allowing e-cigarettes to be sold in the same places to compete with combustible cigarettes. Reducing young people’s access to both cigarettes and e-cigarettes would minimise the recruitment of new smokers and the uptake of e-cigarettes among adolescents and young adults.
Wayne Hall has received funding from NHMRC for research on addiction and cigarette smoking and was commissioned to review the ethical issues raised by the ban on sales of e-cigarettes by VicHealth who bears no responsibility for the views expressed in this article.
Coral Gartner has received funding from the National Health and Medical Research Council, the HIV Foundation of Queensland and VicHealth to conduct research on e-cigarettes.
Cynthia Forlini does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.