E

lectronic cigarettes aren’t good for you in the way that an apple or exercise are good for you. But compared to tobacco cigarettes, they can reduce the harm of smoking. The value of using e-cigarettes as a harm reduction strategy will be a focus of the inaugural US E-Cigarette Summit on Monday. Unfortunately, the specter of the tobacco industry hovers over any policy choices we make on e-cigarettes.

Harm reduction encompasses strategies aimed at reducing harmful physical or social consequences that stem from legal and illegal behaviors. It accepts that individuals will engage in potentially risky behaviors, and so aims to minimize their impact. Examples of harm reduction strategies include providing methadone to heroin users, endorsing the use of condoms to prevent pregnancy and the spread of sexually transmitted diseases, opening needle exchanges to prevent the spread of HIV and hepatitis among individual who inject drugs, and promoting e-cigarettes or smokeless tobacco as alternatives to smoking combustible cigarettes.

Harm reduction interventions reduce some, but not all, of the short-term and long-term risks for any given behavior. It is not necessarily inconsistent with the goal of total cessation or abstinence, but that isn’t its main priority.

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The E-Cigarette Summit replicates an approach taken over the last four years in London. It will provide a neutral forum for critically debating the emerging evidence — and sometimes widely divergent perspectives — on e-cigarettes, as well their implications for public policy. Two core questions will be central to the ongoing debate: Does harm reduction represent an appropriate strategy for confronting the threat posed by tobacco? If so, what evidence would justify such an approach?

A chief challenge to harm reduction in general is that providing a safer alternative fails to address the underlying problematic behavior. With regard to smoking, it means individuals will continue to use nicotine, an addictive substance. There are also concerns that using e-cigarettes for harm reduction might nudge some individuals, especially adolescents and young adults, to take up vaping because it is “less dangerous.” Similar worries were raised when the US first considered needle exchanges.

Harm reduction also throws into question the value of cessation. Why not simply focus on getting people to stop the risky behavior — like drug use or smoking — rather than replacing it with something that poses lesser harms?

Should we settle for lesser harms? Yes. But that requires policymakers to take some risks and accept some risks.

Harm reduction options are often pursued in the face of uncertainty. We don’t know whether they will cause more harm than good until we try them, and sometimes even then can’t answer that question.

During the early years of the AIDS epidemic, American public health professionals embraced harm reduction after intense and often contentious debate. Police officials in Connecticut were some of the first to back needle exchange programs. They recognized that, given the consequences of HIV and the futility of punishing drug users, it was important to take pragmatic steps to reduce the risk of getting AIDS, even though it would not eliminate the risk. This same sensible approach, seen in the form of making overdose-reversing Narcan available without a prescription, is beginning to inform the response to the opioid epidemic.

When it comes to smoking, experts are deeply divided about harm reduction. In part that is because the tobacco industry, which was responsible for 100 million deaths worldwide during the 20th century and possibly 1 billion deaths during the 21st century, could play a central role in developing products that deliver nicotine in a less-dangerous fashion.

This raises an issue that never vexed harm reduction in other domains. Methadone manufacturers didn’t create heroin addiction. Needles weren’t responsible for HIV. Condom companies didn’t invent sex. Tobacco companies, however, created the very problem they are now trying to “help” reduce.

From the 1950s through the early 1980s, national public health institutions and voluntary organizations supported the idea of tobacco harm reduction. In a context in which smoking was the norm, efforts to develop a “safer” cigarette were politically and socially appealing. Enthusiasm for that strategy was snuffed out when it became clear that the tobacco industry had actively suppressed evidence that smoking causes cancer and heart disease while at the same time it had been manipulating nicotine levels in cigarettes to promote addiction.

Some of today’s most vocal e-cigarette opponents are less opposed to harm reduction as a principle than they are to the tobacco industry as one of its champions. We’ve been down that road with the “safer cigarette” and got burned, they say.

At best, making and marketing e-cigarettes represents a conflict of interest for Big Tobacco since it could, in theory, push its main money-making product off the shelves. At worst, e-cigarettes represent a Trojan horse, yet another way to attract smokers and get them hooked on tobacco products, potentially expanding the shelf space of combustible cigarettes after decades of hard-won victories against smoking.

E-cigarettes are not the brainchild of the tobacco industry. Yet big tobacco companies have been quick to develop their own e-cigarettes and buy out independent e-cigarette companies. In either case, e-cigarettes don’t just represent a promising means to help people stop smoking, but also a way to market the recreational use of nicotine. That means an industry in the business of addiction will profit from tobacco harm reduction.

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Policymakers are faced with a hard choice. They can follow the evidence that, while not without uncertainty, increasingly suggests that e-cigarettes can reduce the use of tobacco cigarettes and then support the development of rationally regulated nicotine delivery devices like e-cigarettes. Following this path means tolerating some level of recreational nicotine use, just like clean needles required accepting that not everyone will stop injecting drugs. It also means accepting a role for the tobacco industry.

The other option is to maintain a purist stance — no smoking, no drugs, no sex, no collaboration with the enemy, and therefore no smoking — and impose limitations that will all but assure that e-cigarettes and other non-combustible alternatives to smoking are driven from the open market.

Rejecting e-cigarettes because the tobacco industry will profit from them has the virtue of being uncompromising. But it also means rejecting the evidence and accepting the predictable, deadly toll of cigarette smoking. That’s a virtue, we argue, the world can no longer afford.

Amy Fairchild, PhD, MPH, is associate dean of academic affairs at the Texas A&M School of Public Health. Ronald Bayer, PhD, is a professor of sociomedical sciences at Columbia University’s Mailman School of Public Health.

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  • You keep associating vapor products (Electronic Cigarettes) with big tobacco while they do have some products the truth is their share of the market is completely negligible, in fact the products they create are far less effective than around 99% of the products on the market.

    The real vapor industry is actually made up of a series of small mom and pop type shops with a large portion of it being owned by people that quit smoking via vapor products and it worked so well for them that they want to help others do the same and make a little profit from it. These shops focus on helping people quit and stay off tobacco cigarettes while big tobacco has their toes in the water out of fear they will be left behind.

    Big tobacco on the other hand is starting to push for HNB (Heat not Burn) cigarettes which are still like a cigarette but there’s no combustion which is something completely different that vapor products (electronic cigarettes).

    These small mom and pop shops don’t have the money big tobacco does, most of them make less money than a small convenience store which is why the PTMA process is so scary and will basically destroy most of the market and hand it over to big tobacco that only sells sub-par “Gimmicky” vapor product that aren’t very effective..

  • Something rarely mentioned in these types of discussions on tobacco is the consumer. It is nearly always the same old big tobacco verses the experts in tobacco control. It is a false scenario as it leaves out the most important stakeholder, the actual consumer.

    Another issue that is left out is just how much harm reduction there actually is with low risk alternatives to cigarettes. It is known from decades of studies on snus and other forms of western type smokeless tobacco that the risk is about 99% less for smokeless tobacco then inhaling smoke from cigarettes. This is contrary to the common myth that smokeless tobacco has the same risk as smoking, when in reality it is several orders of magnitude less harmful. It is the smoke that kills, not tobacco or nicotine. Vaping is likely to have about the same low risk as smokeless tobacco.

    That information is being withheld from the public by the medical establishment (who have largely endorsed an abstinence only approach to tobacco) and in the US by our own government agencies (the CDC and FDA among others). Consumers can’t make rational choices unless they have truthful information. If people where truthful informed on the relative risk of different tobacco products there is little doubt that over time the great majority of people who continue to use tobacco would make the choice of the less harmful product. That choice has been taken away by the continued misinformation campaign on smokeless tobacco, and now vaping.

    The solution to the tobacco problem is easy, stop lying. Give people rational choices besides abstinence only quit or die.

  • Good perspective. As a veteran of the HIV harm reduction wars, I recall Dr. Bayer’s many contributions. One quibble, though – the putative smoking cessation benefits of e-cigs are turning out to be exaggerated, for most people. Add to that the fact that e-cigs are an increasing “gateway” to tobacco, and the harm reduction calculation becomes less compelling. Big tobacco wins both ways, unless e-cigs are regulated every bit as strictly as tobacco. Thanks.

    • @Steve Heilig, Your comment contains two assertions both without any evidential support. In fact, the evidence shows the exact opposite. First, as to cessation benefits, today’s news from ASH UK shows that e-cigs are very effective. http://www.telegraph.co.uk/news/2017/05/08/half-british-vapers-have-now-quit-smoking-tobacco-study-suggests/
      Second, the tired gateway argument has no support whatsoever. Again the exact opposite is happening. Smoking is down as vaping increases. Only by ‘deeming’ vaping tobacco use can tobacco use be shown to have failed to fall as fast as we would like, it’s still falling mind, this is obscuring the clear fact that the fastest fall in youth smoking happened with the advent of vaping.
      The whole “just say no” policy has failed with smoking as it did with drugs, alcohol and sex. Time to adopt harm reduction especially as it’s a reduction of more than 95 %.

    • First off, your statements are incorrect, to put it as kindly as possible. The supposed fact that vaping is not effective in smoking cessation is based on statements that were quite literally made up. Actual studies with actual data have shown that vaping is far more effective than all other NRT’s combined.

      Your second statement shows in a very dangerous myth that is quite popular and entirely nonsensical. The closest equivalent I can think of for this myth is stating that barbecue sauce is so delicious that it might inspire people to eat charcoal. I use this analogy because the idea that someone would switch from e-cigarettes, with all the flavors available, to seek out a cigarette with the taste of tar and ash and smoke, seems to me to be the most ridiculous concept.

      There is no reason to switch from vaping to smoking. There is no better sensation or higher nicotine delivery from smoking, period. Once the switch is made, and the ex-smoker’s taste buds recover, the smell and taste of a combustible cigarette is disgusting. The addiction is satisfied by the e-cigarette, rendering the combustible cigarette no longer attractive.
      The liquid used in e-cigarettes is adjustable to different levels of nicotine, customizable to the user’s preference. Anyone saying that the combustible cigarette will somehow be attractive to a vaper simply doesn’t understand what they’re talking about.

      A big component of these myths is that somehow the FDA regulations are hurting big tobacco. In reality, these regulations protect big tobacco. In the vaping community, the “deeming regulations” are referred to as the “big tobacco protection act”. By the FDA’s own statements the best way to comply with the regulations is to create a device exactly like the e-cigarettes that are manufactured by big tobacco companies, which most neighbors find to be sub-par, and are usually abandoned as a smoking alternative. The preferred devices, the types of devices that have successfully allowed so many smokers to leave combustible cigarettes behind, and the accompanying items and juices are cost prohibitive under the FDA regulations.

      Substances that would be GRAS in any other application, including heating on a home stove, would now be subject to retesting at a cost of billions of dollars. Batteries and other accessories available with no added regulatory burdens in other industries would now have to be tested for approval for the FDA. The regulations are so far-reaching that smart phones could now fall under the purview of the FDA. The majority of this industry that has caused the first major event in tobacco sales in decades would disappear – leaving only big tobacco in control. Rather than establishing a safeguard against the types of practices that big tobacco was guilty of for decades, these regulations would reward these very same corporations with a virtual monopoly, pushing products that will cause smoking levels to return to the levels of 2007.

    • Thanks to both Mr Gleeson and “Tony” for responses. But given the content therein, before I bother to add any more, I’m compelled to ask of you both if you have any financial or other interest in any tobacco or vaping concerns? Thanks.

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