01.Too many unknowns
The World Health Organisation (WHO) has released a report on e-cigarettes, recommending restrictions should be placed on the marketing of the devices, their sale to minors, and indoor use.
E-cigarettes, often promoted as a safe alternative to cigarettes and pathway to quitting smoking, have proved highly controversial. While some cautiously welcome them as a potentially healthier alternative for current smokers, at least in the short-term, others are concerned they could undermine efforts to de-normalise tobacco use.
The WHO takes issue with the marketing of e-cigs, with one of the main marketing angles being that they help smokers quit or cut down on regular cigarettes. There are plenty of anecdotal reports of people using e-cigs to wean themselves off smoking and eventually quit altogether, but published research to date has shown that vaping is not necessarily any better than going cold turkey when it comes to quitting.
Even using them to cut down on regular cigarettes may not help. As Professor Simon Chapman, from Sydney University's School of Public Health, points out, "Everyone assumes that if you cut down the number of cigarettes you smoke each day by also vaping, that this will reduce your risk of harm. Unfortunately, four very large cohort studies have all found that just reducing, as opposed to quitting, confers very little health benefit."
Other key problems identified by the WHO are the variability amongst products (hardware and liquids) and hence in the toxicity of their contents and emissions; and their relatively recent entry into the market and the lengthy lag time for onset of many diseases of interest, such as cancer, which means that conclusive evidence about the association of e-cigarettes with such diseases will not be available for years or even decades.
However, the report acknowledges, "it is very likely that average [e-cigarette] use produces lower exposures to toxicants that combustible products," although the amount of risk reduction is currently unknown.
The WHO's priorities are reducing the exposure of non-smokers to exhaled vapour in indoor spaces, and preventing young people taking up e-cigs and perhaps moving onto combustible cigarettes.
It's also concerned about tobacco companies moving into e-cig sales, suggesting their motives lie in "maintaining the status quo in favour of cigarettes for as long as possible, while simultaneously providing a longer-term source of profit should the cigarette model prove unsustainable."
"In addition, selling these products is intended to bring reputational benefits to these companies, as they can pretend to be part of the solution to the smoking epidemic."
The report has been welcomed by public health and tobacco control authorities concerned about the increasing hype around e-cigarettes.
"The clear conclusion is that we should be very cautious about any developments around e-cigarettes," says Professor Mike Daube, President of the Australian Council on Smoking and Health (ACOSH). "The reality is that these products are still new; the potential benefits are still in doubt; and there are significant concerns about possible short and long-term harms."
But others are concerned that it could be dismissing a valuable weapon in the quitting arsenal.
As Professor Anne McNeill, Professor of Tobacco Addiction from the National Addiction Centre, King's College London, argues, “Based on their analysis, the WHO proposes a range of regulations for e-cigarettes and my concern is that these will deter smokers from trying to use them. Cigarette smoking is so uniquely dangerous that anything we can do to encourage smokers to stop should be welcomed."
"Smoking is now concentrated among our most disadvantaged groups in society, for whom I think e-cigarettes could be a game changer.”