The Public Health Case for Electronic Cigarettes

Earlier this month, a federal appeals court blocked the Food and Drug Administration's attempt to ban electronic cigarettes, battery-powered devices that simulate smoking by generating vapor from a propylene glycol solution containing nicotine. An article in the December 9 Journal of Public Health Policy explains why, legal issues aside, the FDA should not be trying to ban this product if its aim is to reduce tobacco-related harm. Boston University public health professor Michael Siegel and Zachary Cahn, a graduate student in political science at U.C.-Berkeley, review the evidence concerning the relative hazards of e-cigarettes and conventional cigarettes as well as the former's potential as a replacement for the latter. "A preponderance of the available evidence shows [e-cigarettes] to be much safer than tobacco cigarettes and comparable in toxicity to conventional nicotine replacement products," they write. Furthermore, because e-cigarettes more closely simulate the experience of smoking than nicotine gum, patches, or inhalers do, they may be more effective in helping smokers quit. Siegel and Cahn note that effectiveness may not hinge on nicotine delivery:

Taken together, this evidence suggests that electronic cigarettes are capable of reducing cigarette craving, but that the effect is not due exclusively to nicotine. Bullen et al observe that "the reduction in desire to smoke in the first 10 min[utes] of [electronic cigarette] use appears to be independent of nicotine absorption."…The sizable craving reduction achieved by the "placebo"—a nicotine-free electronic cigarette—demonstrates the ability of physical stimuli to suppress cravings independently. Many studies have established the ability of denicotinized cigarettes to provide craving relief. Barrett found that denicotinized cigarettes reduce cravings more than a nicotinized inhaler, supporting Buchhalter et al's conclusion that although some withdrawal symptoms can be treated effectively with NRT [nicotine replacement therapy], others, such as intense cravings, respond better to smoking-related stimuli.

Perhaps because of these very same "smoking-related stimuli," public health officials and anti-smoking groups have been irrationally hostile to e-cigarettes, demanding that they be removed from the market. Siegel and Cahn challenge these critics to act on their own professed principles, including the injunction to "do no harm," by supporting e-cigarettes as a harm-reducing alternative to smoking:

Thus far, none of the more than 10 000 chemicals present in tobacco smoke, including over 40 known carcinogens, has been shown to be present in the cartridges or vapor of electronic cigarettes in anything greater than trace quantities. No one has reported adverse effects, although this product has been on the market for more than 3 years….

The evidence reviewed in this article suggests that electronic cigarettes are a much safer alternative to tobacco cigarettes. They are likely to improve upon the efficacy of traditional pharmacotherapy for smoking cessation….

By definition, enacting a ban will harm current users, unless the evidence suggests that the harms outweigh the benefits for those already using the product. The burden of proof is on the regulatory agency to demonstrate that the product is unreasonably dangerous for its intended use….

Unless the evidence suggests that vaping does not yield the anticipated reduction in harm to the user, enacting an electronic cigarette prohibition will do harm to hundreds of thousands of vapers already using electronic cigarettes in place of tobacco ones—a clear violation of nonmaleficence.