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Yesterday, the US Surgeon General, Dr Vivek Murthy, released a report claiming e-cigarette use among young people has become a national public health concern.

The report was intended as a warning to the US public about the growing popularity of e-cigarettes among young people, and the possible harms that nicotine can bring.

It offered several calls to action, including the need to tell the public about the risks of nicotine; plans on banning e-cigarette use indoors; and continuing to regulate them to the same extent as tobacco.

“The products are the most commonly used form of tobacco among youth in the United States,” said Murthy

But there’s one problem: e-cigarettes don’t contain tobacco at all. And public health experts in the UK disagree with Murthy’s interpretation of the evidence.

There is a consensus here in the UK that e-cigarettes are far safer than smoking tobacco.

E-cigarettes contain liquid nicotine dissolved in propylene glycol or glycerine, but they don’t contain tobacco. And for smokers, there is also evidence to show that e-cigarettes are helping people to stop smoking.

If e-cigarettes have the potential to be a vital tool in reducing the harm that tobacco causes, why is there such disagreement about them?

What is harm reduction?

Harm reduction is a type of public health policy that aims to reduce the harmful consequences of substances, or actions, without necessarily reducing or eliminating the use itself.

For example, condoms don’t completely eliminate the risk of sexually transmitted infections, but they reduce the risk of contracting one by about 99%. Same goes for seatbelts and airbags in car accidents.

The UK has always been a leader in harm reduction. In 1926, the Ministry of Health concluded that drug addiction was an illness that should be treated by doctors, sometimes with a minimal dose of drugs in order to prevent withdrawal symptoms.

When AIDS came to the UK in the 80s, the first government campaign on HIV infection among injection-drug users encouraged safer drug practices.

The idea of harm reduction for smoking tobacco has been around for years. In 1976, Professor Michael Russell wrote: “People smoke for nicotine but they die from the tar.” So why, 40 years later, is the topic of how to avoid exposure to the harmful chemicals in tobacco still being debated?

A quick recap of the debate

We’ve blogged about e-cigarettes before, answering some common questions and rebutting a number of misleading media reports of new evidence.

The danger of nicotine was one of the main concerns raised in the Surgeon General’s report. But although nicotine is addictive and has some known harms, it doesn’t cause smoking-related diseases, such as cancer and heart disease. There’s also a common misconception that you can overdose on nicotine using e-cigarettes. But you are in no danger of poisoning yourself, nor have there been any cases of overdose from inhaling the nicotine-containing fluid that an e-cigarette vaporises, known as e-liquid.

And unlike second-hand smoke from cigarettes – which is known to cause cancer – there’s no good evidence that second-hand e-cigarette vapour is dangerous to others.

Another major argument against e-cigarettes is that they could encourage children to start smoking – either by exposing them to nicotine (the ‘gateway’ argument) or by making smoking seem more normal again (the ‘renormalisation’ argument). The US Surgeon General claims that the number of middle and high school students using e-cigarettes has rapidly increased, and this is a key reason the US is taking such a tough approach to e-cigarettes.

We don’t want young people or non-smokers vaping either, but the situation is very different in the UK. Smoking among young people is at an all-time low, and continues to go down. And surveys across the UK last year found that young people who hadn’t smoked weren’t becoming regular users of e-cigarettes.

In England, for example, just 3 in every 100 11-15 year olds are regular smokers, with similar figures in Scotland and elsewhere in the UK.

This is obviously still higher than it should be. But it doesn’t seem that e-cigarettes are fuelling smoking uptake.

The UK has thorough regulations in place to tackle e-cigarette use among young people, including advertising restrictions and a ban on selling devices to under-18s.

So yes, the potential for e-cigarettes to lead to young people smoking is something we should look out for. But we’re not seeing any evidence that it is materialising in the UK.

So why are e-cigarettes so controversial?

Replacing tobacco with safer forms of nicotine is not a new phenomenon. Nicotine replacement therapy, including gum, patches and inhalers, has been around since the 80s. And few people seem to worry about these products.

There aren’t claims they should be regulated in the same way as tobacco, newspapers haven’t splashed scare-mongering headlines across their front pages, and public health experts don’t seem to be trolled on social media for stating their opinions about the products.

But at the same time, nicotine gum doesn’t come in thousands of different flavours, you probably haven’t come across any ‘nicotine-nasal-spray festivals’, and you wouldn’t find an article about nicotine patches in the Rolling Stone.

Vaping has become a cultural product in the way that other stop smoking aids haven’t. And this is why people are so concerned that they will appeal to young people.

This is a legitimate worry and further research is needed, but the evidence that’s available so far shows this isn’t the case.

Where do we go from here?

E-cigarettes are still new products to the market, so there’s a lot that still isn’t known about them.

There’s a need for more research, but we can be confident in the UK that arguments about e-cigarettes being a gateway to taking up smoking are not based on evidence.

Studies show that children aren’t using e-cigarettes in great numbers and the continued decline in smoking among young people shows no evidence for e-cigarette users becoming long-term smokers.

We don’t know what the long term effects of these products will be, but there is likely to be some harm associated with their use. E-cigarettes aren’t 100% safe. But very few of the things we do each day, or the products we buy, carry no risk at all.

This is the nature of harm reduction.

This principle has been embraced in the UK where there is a regulatory system which makes the most of the opportunity of e-cigarettes while being aware of the potential risks.

The evidence is showing e-cigarettes can help beat the tobacco epidemic. And when they have the potential to save millions of lives, should we just sit back and wait?

Alyssa Best is a policy advisor at Cancer Research UK

Comments

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julesb January 9, 2017

I am an ex smoker, I stopped, cold Turkey,18 years ago, after a few false starts. I wasn’t a heavy smoker, but it still wasn’t easy. My husband was a heavy smoker, who tried patches, sprays and gum, none of which stopped him smoking, though Gum did cut him right down, but gave him mouth ulcers, to the point he couldn’t use it any more.

Since he took up vaping, he has stopped smoking entirely and hasn’t had a cigarette in several years now, hurray! However, it isn’t all good news, he still buys the strongest solution and cannot seem to cut back on the vape, he is addicted to that instead now. He only likes the tobacco flavours, which I hate the smell of (almost as much as I hate cigarette smoke.) The odour can be ‘aired’ from the room, but his clothes smell and so does his breath, and it turns his tongue brown! He thinks I just exaggerate ….

He may be at less risk of cancer, I certainly hope so, but I feel the habit itself is almost as anti-social as smoking, a faceful of vape mist at a concert, is not pleasant, so I can understand the reactions of some on here and why they might welcome the legislation, even though it doesn’t seem fair or quite logical.

I think a few children will take to it because it’s ‘cool’ and their friends do it, just as I did with cigarettes so many years ago, and as they probably would with cigarettes, if vaping wasn’t invented, so I am keeping my fingers crossed that it is the lesser of two evils in the long run

Spiro January 5, 2017

Smoked my last cigarette 5 years ago, the day I started vaping. Have tried many times over the years to give up, without success, with vaping it was easy.
Trouble is, tobacco lobby caught on back foot, frantically trying to play catch up, and trying to damage the vaping industry through well funded dubious PR, leading to nonsensical legislation such as TPD.

Rick January 5, 2017

Just like cigarettes, vaping also pollutes the atmosphere and it means that non-smokers have to breath in the output from these revolting devices. Both forms of smoking should be outlawed everywhere except for in the private homes of the addicts themselves.
Nowadays, non-smokers are effectively prevented from enjoying a meal outdoors at a restaurant! Frankly, that’s an infringement on a non-smoker’s rights of access to clean unpolluted air.

Janette January 5, 2017

I smoked for many years, many attempts to quit too. I took up vaping to see if that would be a means to help me to stop and it worked. Not one more regular cigarette since day 1. I gradually reduced the strength of nicotine in the eliquid. I suppose I am hooked on vaping now, but I enjoy it and I believe it is MUCH LESS harmful than smoking. And as far as young people taking up vaping, I would say that almost all the people I see with ecigs are in the 40+ age group – most likely ex-smokers. I see it as a bit like alcohol. Over indulging is bad for your health. Total abstinence would probably be best, but an occasional drink must be better than heavy drinking.

Tomasz F. January 5, 2017

I never smoked a cigarette in my life, and I developed sort of a hate towards people smoking near me without any care for my health. You see, the problem I see with e-cigs is that vaping now became allowed in offices, public places, and lately even in tight spaces like buses and trains, just because it’s considered such a low harm. The only choice I have is to leave the place, or move somewhere else. Now that the e-cigs are promoted as “so safe” for smokers, and come in flavors, vaping in public suddenly became acceptable again. You see, e-cigs are becoming popular among young people not only as a replacement for cigs, but also because it’s cool. I met a few young people who would do this just because it’s the thing now! Isn’t this a concern? It was the same with cigarettes in the 60-90s, they were cool to smoke.
I don’t want any smoke to be part of the air I or my family breathes, and as such I really am against any acceptance of such a drug in the way it is. I think they should be regulated in the same strict way as cigarettes.

Timothy Green January 5, 2017

Having over heard a group of pompous promoters of cigarettes at an indoor tennis tournament back in 1987, saying that as British sales of cigarettes were falling. They badly needed and they represented Benson & Hedges by the way! To get the children of the sub-Indian continent and the pacific basin countries, hooked upon tobacco at a very early age! So as to safeguard their industry, for health laws were lax in these then third world countries. I am opposed to any form of device that proposes to be an alternative to smoking tobacco, as their will always be health problems. The reason being is obvious and should also be to these medics in favor of so called E-Cigarettes as the human respiratory system was meant to breath a clean earth atmosphere, free as much as possible from pollutants. These alternatives are just a way of making money for those in fear of their industry going to the wall. If you don’t encourage to stop these Doctors, who are very likely in the pockets of big business I am likely not to support Cancer Research UK in the near future!

Alex December 15, 2016

Such incredible ignorance from Dr Murthy, one would be forgiven for thinking he’s taking back-handers from big tobacco.

Certainly good to err on the side of caution with e-juices. Absence of evidence isn’t evidence of absence after all, but to equate e-cigarettes with analogue cigarettes seems recklessly irresponsible.

Carl B December 14, 2016

I find it a little baffling how the UK seem to be out of step with a large proportion of the world on this issue. As a country the UK has researched the products and provided sensible health information. Here we view ecigs as an alternative to smoking and a means of quitting traditional cigarettes. They are by no means perfect but in comparison to smoking our studies show they are a much better health option. Around the world ecigs appear to be viewed as a stand alone product, i.e. vaping is worse for your health than not vaping with little to no regard given to smokers who switch. It seems that the US and EU are set on a path of banning or regulating to the point of destroying the industry. Hopefully in years to come they can look at the UK and like minded countries and realise their hard line approaches were a mistake.

Eff December 13, 2016

Great article. What I do find utterly baffling is the changes due in April thanks to the TPD which affect both tobacco AND egis. First of all – eliquid is not a tobacco product. But most baffling of all is that in April, smokers while now have to buy MORE cigarettes if the want to smoke, as packs of 10 will no longer be available, but vapers will now have to buy LESS eliquid, the maximum amount of liquid a person can buy is just 10ml, which will increase costs of harm reduction i.e. vaping. This is real Alice in Wonderland logic.

Dr. Marilyn Leahy CCFP December 13, 2016

This is an excellent discourse on the importance of clarity and accuracy of fact in shaping health policy and ultimately societal habit. We need more of this type of discussion. Let’s really pay attention to what is helpful and what is harmful, and make sure advice given by “experts” is sound.

Fred Saj December 13, 2016

Well it all depends, I am 20+ and I think vape is much better than smoking, I really love vaping and try different flavors :)
I know its harmful but I can’t help it, I really love vape and I can’t leave it

Philippe Arvers, MD, PhD December 10, 2016

That’s great !
In France, it’s too early to hear the same thing from our health authorities.
We just started this year your “Stoptober” last november. So …

Fr. Jack Kearney, M.Div., CATC IV, CATE December 9, 2016

Thank you for a great article. On behalf of Americans I applaud your approach, and apologize for ours.