They are better than smoking the real thing as they can wean smokers from bad habits and reduce tobacco-related diseases
Electronic cigarettes are recently developed products that have created intense controversy among the scientific and public health community. The uproar was expected considering the fact that e-cigarettes contain nicotine and their use resembles smoking. However, both these characteristics are crucial for the role of e-cigarettes in tobacco harm reduction. But what is tobacco harm reduction? It is a strategy to reduce harm from risky behaviours through the use of less harmful alternatives. It is an approach as we use in our every day lives. The use of seatbelts and helmets are typical cases of harm reduction — in this case the aim is to reduce risks of injury and death in accidents. And while the use of cars and motorcycles is essential (going to work and transferring goods), no one ever suggested that the use of cars for recreation, as when we go for a trip on weekends with our family, should be banned because of the risks associated with accidents.
The same concept applies to tobacco harm reduction, considering the difficulty in quitting smoking and the use of other harmful tobacco products. Tobacco harm reduction is based on the absence of combustion, which is a process that creates almost all of the toxins that a smoker inhales, resulting in high risk for disease and death. E-cigarettes have no combustion and do not contain tobacco. Available scientific evidence provides that e-cigarettes are by far less harmful than smoking. In fact, they fit perfectly to the definition of tobacco harm reduction.
But why is it hard for people to realise the potential of these products? The key answer to this lies in the demonisation of nicotine. That was understandable in a period when the only source for nicotine intake was the harmful tobacco cigarette. But the use of nicotine through a non-combustible less harmful source has been proven to be of little harm. In the US and the UK, health authorities have approved the long-term (even life-long) use of nicotine in the form of pharmaceutical nicotine replacement therapies as smoking and tobacco substitutes, acknowledging that there is no circumstance in which nicotine intake through a clean product would be more harmful than smoking. In that respect, tobacco harm reduction with the use of products such as e-cigarettes can offer tremendous opportunities.
For start, this is an intervention that costs nothing to tax payers and the Government. These products are self-funded by users, do not require expertise and organised smoking cessation clinics and are not subsidised by the healthcare system. In fact, trying to provide access through prescription would be disastrous; e-cigarettes are chosen based on the smokers’ self-preference, making it impossible for any healthcare professional to understand which product would fit the needs and preferences of every smoker. Thus, in countries with limited availability and accessibility to organised smoking cessation clinics, e-cigarettes represent an amazing opportunity for smokers to quit. Additionally, these products represent a new business challenge. Local development and production of e-cigarettes can open up new business opportunities, develop a new flourishing industry while serving public health and creating products that fit better to the needs of the local community.
Of course, all products, including e-cigarettes, need to be regulated. This is not a complex task. The European Union has created a simplified and easy-to-comply regulation that has been implemented since 2016. While not perfect, it can form the basis for regulatory decisions in any country. According to the regulation, e-cigarettes are not medicinal products and they are clearly distinguished from combustible or other harmful tobacco products. The latter is a key factor — any framework should be based on a clear differentiation between tobacco cigarettes (or other harmful forms of tobacco) and e-cigarettes so that smokers have a clear understanding about the risk difference between products. Quality standards should be set, which should be reasonable and not make the products unnecessarily expensive. Marketing should be regulated so that only smokers and users of other harmful tobacco products are targetted. Finally, taxation should be avoided because of the role of these products as smoking substitutes; in that respect, any taxation would favour use of cheaper but very harmful tobacco products.
E-cigarettes have a strong potential for a positive public health impact. Such an impact has already been documented in countries where they have been available for years, such as the UK. As for India, where access to smoking cessation services is difficult and tobacco use has a deep cultural background, there is an even stronger potential to reduce tobacco-related disease and death. Banning e-cigarettes would be a perfect ‘gift’ for tobacco and would strongly (though unintentionally) protect tobacco cigarette sales.
(The writer is a research fellow, Onassis Cardiac Surgery Center and at the Department of Pharmacy, University of Patras, Greece)
