We tend to become like the worst in those we oppose.
Frank Herbert

As discussed above, the issue with cigarettes turns on combustion not on nicotine. If it were possible, therefore, to deliver nicotine without combustion there should be a benefit to an individual’s health and therefore to “public” health. This is genesis of the concept of the electronic cigarette, the first version of which was patented in the 1960s.

The debate about the e-cigarette market has been played out in scientific circles, the media and in the investment industry. There are very many, strongly held views on all sides regarding safety, regulation, usage, targeting, product design, the role of the existing tobacco industry and the potential costs and benefits to users and society more generally.

The UK has been seen as one of the most progressive nations with respect to e-cigarettes with both endorsement from Public Health England and a licencing programme for Nicotine Containing Products as Medicines. By contrast e-cigarettes are banned in Australia, Argentina, Hong Kong, Mexico and Singapore, for example. How can it be that there are such divergent views?

The argument in favour of e-cigarettes is fairly straightforward: e-cigarettes do not contain tobacco and do not involve combustion; there are typically only four components to the aerosol inhaled by consumers namely propylene glycol (glycerine), water, flavourings and usually – but by no means always – nicotine; they do not produce smoke.

There is a weight of scientific evidence that e-cigarettes do not expose users to the risks of combustible cigarettes. The veracity of the claim that e-cigarettes are “95% safer” than cigarettes is a different matter, but to be able to say that for those that wish to continue using nicotine but do not want the risks of smoking that e-cigarettes are “a good thing” seems justifiable, and sensible.

Countering this there are various strands of arguments used against e-cigarettes; that it is too early to tell if harm is genuinely reduced; that there are potential risks from e-cigarettes either from “fine particles” or from certain chemicals contained in vapour; that they “renormalize” smoking; and that they will act as a “gateway” product initiating youth into nicotine addiction which will inevitably lead to cigarette smoking.

The headlines regarding the potential risks of e-cigarettes have received much coverage and have resulted in a situation where survey data suggests that uncertainty regarding the relative safety of e-cigarettes has been increasing rapidly.

Chart 7: Adult population perception of harm from e-cigarettes relative to smoking (2013-2016)

Chart 8: Positive v Neutral or negative, 2013 (%)

Chart 9: Positive v Neutral or negative, 2016 (%)

This level of uncertainty is important for a number of reasons. Firstly for smokers considering vaping as an alternative to smoking, if there is uncertainty of any health benefit the decision to cease smoking may not be made which seems entirely counter to the objective of “public health”. Secondly the survey is not of e-cigarette users but of the general population. If the general public is not convinced that vaping is safer than smoking then the same approach of regulating vaping in “public places” can be pushed through by playing on the same, engineered, perception of “second hand” risk.

Perhaps one of the major stumbling blocks in the growth of the vaping trend has been that the original claims made by many manufacturers that “you can vape anywhere” have been undone by increasing levels of regulation which precludes vaping in the same places that smoking is already restricted. Vaping bans are already common on airlines, public transport, pubs and at least one major global financial institution which once employed me. In the latter case the arguments against the use of e-cigarettes on company premises included that the FDA had not ruled on them; the American Cancer Society had not ruled on them; they were “a bit smelly”; and that they may present a visual distraction for those trying to quit smoking. On this latter point, those on a diet were not prevented from entering the canteen despite the visual distraction that food might have presented.

In November of 2016 WHO will hold the 7th “Conference of the Parties” to the Framework Convention on Tobacco Control. It has released the documents for the five day conference, including one on “Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems”. The document raises a number of issues pertinent to the debate about e-cigarettes, but also to the debate about tobacco control more generally.

The document is equivocal on the potential health benefits of vaping relative to smoking and quotes of the risks a number of claims which have been roundly dismissed elsewhere but does state that “it is very likely that ENDS/ENNDS are less toxic than cigarette smoke”. It also states that it is “reasonable to assume that the increased concentration of toxicants from second hand aerosol (SHA) over background levels poses an increased risk for the health of all bystanders”. It argues that “given the scarcity and low quality of scientific evidence, it cannot be determined whether ENDS may help most smokers to quit or prevent them from doing so”. It is uncertain that ENDS/ENNDS use in youth is a precursor to smoking (i.e. “the gateway effect”) but states that “ENDS/ENNDS use by minors who have never smoked at least doubles their chance of starting to smoke”. It also finds that “A growing concern is the extent to which research on the topic has links to commercial and other vested interests of the ENDS/ENNDS industry, including the tobacco industry, and its allies. In a review of 105 studies analysing the composition of liquids and emissions, 30% had authors that had received funding from ENDS/ENNDS interests – including the tobacco industry”.

The paper concludes with four objectives:

• prevent the initiation of ENDS/ENNDS by non-smokers and youth with special attention to vulnerable groups
• minimize as far as possible potential health risks to ENDS/ENNDS users and protect non-users from exposure to their emissions
• prevention of unproven health claims being made about ENDS/ENNDS
• protect tobacco control activities from all commercial and other vested interests related to ENDS/ENNDS, including interests of the tobacco industry

To achieve these objectives 28 recommendations are made including

• Banning or restricting advertising, promotion and sponsorship of ENDS/ENNDS
• Taxing ENDS/ENNDS at a level that makes the devices and e-liquids unaffordable to minors in order to deter its use in this age group.
• combustible tobacco products should be taxed at a higher level than ENDS/ENNDS to deter initiation and reduce regression to smoking
• Banning or restricting the use of flavours that appeal to minors
• Regulating places, density and channels of sales
• Taking measures to combat illicit trade in ENDS/ENNDS
• Regulating electrical and fire safety standards of ENDS/ENNDS devices
• Prohibiting by law the use of ENDS/ENNDS in indoor spaces or at least where smoking is not permitted
• Requiring health warnings about potential health risks deriving from their use
• Prohibiting implicit or explicit claims about the comparative safety or addictiveness of ENDS/ENNDS with respect to any product unless these have been approved by a specialized governmental agency
• Rejecting partnerships with the industry
• Banning activities described as “socially responsible” by the industry, including but not limited to activities described as “corporate social responsibility”

There is a somewhat inevitable collection of ban-tax-regulate in the list of recommendations despite the somewhat limited evidence of success from similar strategies in combustible cigarettes. There is also an interesting juxtaposition of a desire to see higher prices for ENDS/ENNDS and an acknowledgement that higher prices (and other regulation) may well see an increase in illicit trade. The regulation of electrical and fire safety standards is also illuminating given the recent experience of Samsung with another battery-powered, habit-forming product which is definitely aimed at youth.

There is very little in the objectives or recommendations for action which suggests that WHO will be taking an encouraging stance towards e-cigarettes in our view, in marked contrast to the much more liberal view taken in the UK. There is certainly no suggestion that those countries which currently have bans on e-cigarettes should consider revoking them. It appears that WHO is being somewhat selective in its choice of research to consider, and is willing to put more credence to reports which highlight risks than those which suggest lessened or negligible risks. The claim is made in the document that in “one review of 105 studies analysing the composition of liquids and emissions, 30% had authors that had received funding from ENDS/ENNDS interests – including the tobacco industry” (para 27). The report itself has been thoroughly debunked by Clive Bates who points out that “many researchers in this field have undisclosed conflicts relating to funders, regulators, employers’ prior policy positions, and their long-held beliefs”. In this respect while it is usual to flag conflicts that arise from association, even vague, with the tobacco industry it is not usually regarded as a conflict if funding has been provided by the pharmaceutical industry, even when those companies may be directly in competition in the provision of nicotine via Nicotine Replacement Therapies.

The hostility of certain parts of Public Health looks set to bring about a number of outcomes which are directly opposed to what we would generally assume to be the objectives of Public Health, and certainly counter to the objectives of ASH described above. In particular the introduction of material regulation of product required by the FDA, for example, will involve material barriers to entry for smaller companies. During 2012 there was much focus from investors with regard to the potential of e-cigarettes, and of the anti-tobacco commentary which was demanding increased regulation was based on the fear of “Big Tobacco” dominating the industry. In actual fact the tobacco companies were somewhat late to the subsector, but as regulation has increased their financial firepower and long history with being regulated actually cement their position at the expense of the innovative smaller companies which originally built the sector.

The fear about “gateway” products based on fruit flavours which “only appeal to youth” ignores the clear testimony of many former smokers who have moved to vaping and then moved quickly away from tobacco-flavoured (and nicotine containing) e-liquids. As data from the UK shows, one third of current vapers use tobacco flavours but half use non-tobacco flavours including fruit (22%), mint (22%), vanilla (3%), chocolate/desserts/sweets (3%), coffee (2%) or alcoholic or energy/soft drink flavours (2%). While WHO decries the lack of scientific evidence in support of reduced-harm claims, there is even less support for the idea of e-cigarettes acting as a gateway to smoking especially given on-going declines in youth smoking rates according to, for example, US data. Put simply while there appears to be growing use of e-cigarettes among US youth, the rate of decline in smoking has accelerated and that alone seems to call into question any validity to the argument that vaping is a gateway to smoking.

It begs the question as to why should WHO and some elements of Public Health be so against vaping? It appears that as much as e-cigarettes have the potential to be disruptive to the combustible cigarette market, so they have been disruptive to the approach employed for so long by the anti-tobacco movement. The message has therefore morphed from “quitting smoking” to “quitting nicotine” but also beyond that as the WHO’s discussion paper makes clear by also now considering not only nicotine-containing electronic products but also those that do not. Mission creep is quite clear. Perhaps this is due to the (anecdotal, it would be said by critics) evidence that quit attempts increasingly use e-cigarettes and not the commonly advised combination of pharmaceutical nicotine products and Government-sponsored professional advice. Of course it is also worth noting that e-cigarettes are a free market solution, not one that has been inspired by or funded by Public Health.

Figure 6: Aids used in most recent quit
attempt, UK

We started this section with the observation that “We tend to become like the worst in those we oppose”. It appears that this is certainly the case with some of the most vocal opponents of e-cigarettes from within Public Health, and the arguments between opponents and proponents becoming particularly vitriolic.

In the Lancet, in an unattributed editorial, the position of Public Health England was dismissed as “the opinions of a small group of individuals with no prespecified expertise in tobacco control” which seems a harsh judgement on a group which included

• the head of the Nicotine Research Group at the Institute of Psychiatry, Psychology & Neuroscience, King’s College London
• two Lecturers and a research assistant in Addictions in the Nicotine Research Group, KCL, and
• the director of Health and Lifestyle Research Unit at Wolfson Institute of Preventive Medicine, Queen Mary University of London