Experts debate: How tightly should e-cigarettes be regulated?

Both Republicans and Democrats want to see more regulation of the e-cigarette industry, a new poll from STAT and the Harvard T.H. Chan School of Public Health finds. But what should those regulations look like? We asked several experts for their views. All agreed that e-cigarette regulations should include language about safety — the devices should be safe to operate, the liquid they use should be free from contaminants or toxins, and the devices and liquid containers should be childproof. Beyond that, a variety of suggestions are on the wish list.

Sue Curry: Crack down on ads that glamorize vaping
Jennifer Unger: Extend smoking bans to cover e-cigs
Neal Benowitz: Limit temperature for heating coils
Lawrence O. Gostin: Regulations should prompt smokers to switch
Vaughan Rees: Finding the regulatory “sweet spot” will save lives

By Sue Curry: While we await evidence about the balance of benefits and risks of electronic cigarettes, we already know that their use is increasing among youths and that it leads some of them to start smoking combustible cigarettes.

Electronic cigarettes are being sold today as tobacco products and should be regulated as such by the FDA. One of the cornerstones of FDA regulations on conventional cigarettes is language to keep them out of the hands of children. The same should hold for electronic cigarettes. We need to ensure that they can’t be sold to minors, and we must ban advertising that glamorizes and normalizes their use.

I find it troubling to see ads for electronic cigarettes, many of which take a page from the old cigarette marketing playbook, with the use of celebrities, glamorous models, flavorings that appeal to the younger crowd, and product placements.

The FDA should further require companies to provide data about the composition of the nicotine cartridges and the health effects of the many compounds that accompany nicotine in the aerosol (tiny particles suspended in air) inhaled by electronic cigarette smokers.

Since we know so little about the safety of these new products, regulations should also create a system for reporting adverse events, such as the recent death of a toddler in New York from drinking a vial of liquid nicotine.

Sue Curry, PhD, is dean of the University of Iowa College of Public Health and professor in the Department of Health Management and Policy.

By Jennifer Unger: Existing bans on smoking should be expanded to include e-cigarettes. Currently, individuals can use e-cigarettes in some places where traditional cigarette smoking is not allowed. This has the potential to expose nonsmokers to toxic chemicals in the aerosol emitted by e-cigarettes. It may also convey the message that smoking is acceptable.

Regulations to prevent adolescents from buying e-cigarettes are also needed. The dessert and candy flavors of e-cigarettes are especially attractive to youths, and doing smoke tricks with the vapor has become popular on Instagram and YouTube.

Adolescents will be attracted to these products and curious about trying them. The problem is that e-cigarettes can get them addicted to nicotine, which is an extremely difficult addiction to break. Nicotine also has harmful effects on the developing adolescent brain. Carefully written regulations could protect a new generation from becoming addicted to nicotine.

Jennifer Unger, PhD, is a professor of preventive medicine at the University of Southern California’s Keck School of Medicine, where she is a co-investigator with the Tobacco Center of Regulatory Science.

By Neal Benowitz: Vaporizing the liquid used in electronic cigarettes can generate chemicals called aldehydes, which have been linked to the development of cardiovascular disease and cancer. The concentration of aldehydes in the vapor increases markedly at high temperatures. The vaporization temperature is determined by the battery strength and the nature of the heating coils. I would want the regulations to specify an upper temperature limit for the heating device to minimize aldehyde generation.

The label should warn that the use of nicotine-containing electronic cigarettes could be addictive. Beyond that, we don’t really know the long-term health effects of electronic cigarettes. Perhaps the warning on the label should say that the health risks aren’t yet known but, based on our knowledge of the toxicity of nicotine, that there are concerns about the use of nicotine during pregnancy, that nicotine may increase the risk of cardiovascular disease, and that it may affect the maturation of the adolescent brain.

Neal Benowitz, MD, is a professor of medicine at the University of California, San Francisco and a member of UCSF’s Center for Tobacco Control Research and Education.

By Lawrence O. Gostin: The best e-cigarette regulations would prompt smokers to switch completely to e-cigarettes while also preventing new e-cigarette users from moving on to smoking or relapsing back into it. How to do that? By minimizing the nicotine levels allowed in cigarettes and other smoked tobacco products so they no longer satisfy the nicotine addiction of existing smokers or new e-cigarette users. That would do more to reduce overall public health harms than any other regulatory approach — short of banning tobacco altogether.

To maximize gains and minimize harms, the FDA should allow e-cigarettes on the market only as a less-harmful alternative to smoking or as FDA-approved smoking cessation drugs. That would mean allowing their sale only to individuals who will use them as an alternative to smoking regular cigarettes, and allowing e-cigarette ads only through direct communications to smokers and former smokers now using e-cigarettes.

With all that in place, whether e-cigarettes have a warning label would not matter as much. But a useful label might say: “This product can be used beneficially only as a complete substitute for any and all tobacco smoking. To reduce all harms and risks, all tobacco and nicotine use should be terminated as soon as possible.”

Lawrence O. Gostin, JD, is University Professor at Georgetown University in Washington, D.C., where he directs the O’Neill Institute for National and Global Health Law.

By Vaughan Rees: What to do about regulating e-cigarettes represents one of the biggest public health dilemmas of this generation. With their potential to deliver fewer harmful toxins than combustible cigarettes, e-cigarettes may represent an unheralded opportunity to reduce the harm associated with tobacco use. Swapping conventional cigarettes for e-cigarettes could prevent many of the 1 billion deaths the World Health Organization estimates will be caused this century by smoking.

At the same time, the uptake of e-cigarette use by adolescents is worrisome. That could create a new generation of nicotine addicts, many of whom would be vulnerable to marketing pressures from manufacturers of traditional cigarettes, thus perpetuating the tobacco epidemic.

E-cigarette regulations should focus on preventing use by youths while providing a lower-risk alternative for current smokers. Fortunately, we have a model in successful strategies developed for the control of tobacco, several of which have been proven to lower the use of tobacco products by youths. These include:

• Banning mass media advertising.
• Banning appealing candy and exotic flavors.
• Restricting adolescents’ access to retail and Internet sales.
• Banning low-priced singles.
• Increasing the cost of smoking by implementing excise taxes.

All of these should be applied to e-cigarettes. By using sensible, proven regulatory approaches, we can offer smokers a less-harmful option while minimizing the demand for nicotine products by youths. Finding the regulatory sweet spot will save hundreds of millions of lives.

Vaughan Rees, PhD, directs the Center for Global Tobacco Control at the Harvard T.H. Chan School of Public Health.