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.
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
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.
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