An area as grey as the vapour it produces: that may be an apt way of describing the current state of debate on e-cigarettes. The pluses and minuses associated with smoking e-cigarettes are many, varied and all the subject of fierce debate. For every voice saying that it normalises smoking from a young age, act as a gateway to more illicit substances, and contain toxic chemicals, themselves, there are other voices claiming that they are less addictive than cigarettes, can help aid smoking cessation and pose fewer health risks.
While the health risks continue to be debated fiercely, as highlighted in this excellent article in the British Medical Journal by Jonathan Gornall, there can certainly be no denying that the use of e-cigarettes has exploded in the last few years. A report commissioned by Public Health England in 2014 titled “E-cigarette uptake and marketing” highlighted the extent to which e-cigarette use had boomed since the beginning of the decade.
It states: “The e-cigarette market is estimated to be worth £91.3 million a year. It increased by 340% in 2013 to reach £193 million and is expected to be worth £340 million by 2015.” This massive increase was mirrored in the US where sales topped $2 billion in 2013, with sales expected to reach $10 billion a year by 2017. Marketed as a cheaper, healthier alternative to smoking, it has positioned itself as a trendy accessory or as something socially attractive (which many point to being quite similar to the way cigarettes were marketed back in the day). Celebrity endorsements have recently followed suit, with notorious ‘ardman Vinnie Jones becoming the first celebrity to endorse an e-cigarette product in a television advert recently. Similarly, the likes of Leonardo DiCaprio, Michael Fassbender and Kevin Spacey have been spotted vaping (in Spacey’s case, the vindictive, sly Frank Underwood smoking an e-cigarette in House of Cards invokes the “Greed is good”-loving, cigar-smoking, all-round bad guy, Gordon Gekko in Wall Street).
A disturbing aspect of e-cigarette use has, undoubtedly, been its take-up among children and young people. A recent American study suggested that almost 1 in 5 15/16 year olds in America had smoked an e-cigarette in the last 30 days. The lead investigator of the study commented: “As one of the newest smoking-type products in recent years, e-cigarettes have made rapid inroads into the lives of American adolescents… Part of the reason for the popularity of e-cigarettes is the perception among teens that they do not harm health.” Figures for those who had tried e-cigarettes were similar in another recent UK study, which also suggested that 16% of teens who had used e-cigarettes had otherwise never smoked.
While the Public Health England report highlighted the e-cigarette advert banned for its likely to appeal to children, as well as another banned before the watershed, its effect specifically on children is unclear. While the report acknowledges that one such advert, taken as an example which gives a snapshot of industry marketing as a whole, featured ‘two good-looking healthy young adults running through smart modern city stress at speed – fast, fit, sexy, healthy, cool’ they also admit that there has “been very limited research on this element of e-cigarettes to date.”
Professor Mark Bellis, from Liverpool John Moores University, put it rather well when he said: “Such rapid penetration into teenage culture of what is essentially a new drug-use option is without precedent.”
While we cannot deny that e-cigarettes now occupy a large space in the consumer landscape, whether or not that is a good thing is hotly debated. The recent decision made by the Welsh Assembly to ban the use of e-cigarettes in public places is one such example that showed how the dividing lines have become quite stark on the issue.
Health and Social Services Minister, Mark Drakeford, said: “The Welsh government has a responsibility to create the conditions which enable people to live healthy lives and avoid preventable harm to their health… We want to get the balance right between all the things that would make a big difference to people’s health and wellbeing in the future.” Chief Medical Officer, Dr Ruth Hussey, added: “This Bill will help to keep pace with emerging public health concerns.”
The reaction to this decision, from both the media and various influential health groups, however, was overwhelmingly negative. The Telegraph led with the rather blunt headline of “Why the Welsh are crazy”. A Guardian comment piece called the move “irrational nanny statism at its worst”. And the Times opted with “e-cigarette ban is typical of petty Welsh politicians.”
Furthermore, diverse groups such as Action on Smoking and Health, Cancer Research UK and British Heart Foundation Wales all criticised the move, saying the move will be “potentially damaging rather than enhancing public health” and that there is “insufficient evidence” to introduce a ban.
Rather curiously, the media coverage, in itself, was interesting. In the publications mentioned above, none of them reported the groups in favour of the decision, opting instead to focus on the negative reaction. This, in itself, is mirrored across the media coverage of e-cigarettes as the “safer, healthier” alternative to cigarettes.
ITV, however, quoted the British Medical Association Wales’ statement in support of the ban, where they commented: “Robust controls are required to ensure the use of e-cigarettes does not undermine existing restrictions on smoke-free public places and workplaces, by leading people to believe it is acceptable to smoke.” Similarly, the view of the Royal Pharmaceutical Society was largely ignored. They commented: “If we don’t act now, there is a danger smoking will become the ‘normal’ thing to do again. E-cigarettes could become the gateway to tobacco. We do not believe this is a risk worth taking. Nicotine is an addictive substance and e-cigarettes are currently not licensed and regulated, so we don’t know what’s in them or their long-term effects on health.”
This, in a microcosm, is an illustration of how the debate rages on and on concerning e-cigarettes. Supporters of vaping say that, because it’s so much less harmful than cigarettes, that its use should be encouraged. It is also said to aid smoking cessation. As well as that they point to a lack of definitive evidence that its use is high among young people, that it ‘normalises’ smoking and that it acts as a ‘gateway’ to other substance abuse. Since smoking has such a detrimental effect on public health, anything which encourages smokers to ditch the damaging nicotine habit, albeit in smaller doses, is welcome, according to its supporters. Big Tobacco is still as big as ever, so any steps to tackle the chronic effects of smoking on the general population should be encouraged.
Sheila Duffy, chief executive of ASH Scotland, summed this up when she commented: “The right regulatory framework for e-cigarettes will require a careful balancing act… The urgent priority is to reduce the enormous harm caused by tobacco use. We believe that e-cigarettes will prove to be much less harmful than smoking – so for a smoker to switch from tobacco to electronic cigarettes will bring significant health benefits.”
Much concern about e-cigarettes, and those who call for more rigorous controls on them, is due to the fact that we really don’t know enough about them yet. Studies have indeed claimed that they are 95% safer than cigarette use, but, as these products are barely a decade old, and certainly only gaining wide use in the last 5 years, that it’s impossible to know the long term effects yet. Furthermore, as tobacco has been shown to have a negative impact on our health, caution is infinitely more advisable when dealing with this new product.
A report by the World Health Organisation emphasised this uncertainty. It highlights that the evidence to date is inadequate to reach a definite consensus on e-cigarettes. They said: “The evidence for the effectiveness of [e-cigs] as a method for quitting tobacco smoking is limited and doesn’t allow conclusions to be reached.” They also highlighted: “Most [e-cig] products have not been tested by independent scientists but the limited testing has revealed wide variations in the nature of the toxicity of contents and emissions.”
In addition, the WHO’s expresses concern that the introduction of e-cigarettes to the smoking debate has effectively altered the key messages around smoking cessation. They add: “The entry of [e-cigarettes] in the market has created challenges to the core message of tobacco control, which until now has been that tobacco use should not be started and if started it should be stopped.”
It would seem, following along these lines, that supporters of e-cigarettes, aside from the Big Tobacco companies and their targeted marketing, see it in a pragmatic fashion as a lesser evil. Something which may not be great, but it’s not as bad as that other thing (reminiscent of the problem facing the Greek public at the minute: austerity may be bad, but the country’s financial system completely collapsing may be far worse). Backing their claims up with scientific evidence may be missing the point that there simply hasn’t been enough time to gauge e-cigarette’s effect: on cessation, on its prevalence, on its attractiveness, on young people. “We know just how bad smoking is so, if you need to smoke, do this instead” seems to be a key message. Imposing controls like the Welsh public space ban discourages people to ditch smoking in favour of e-cigarettes, hence the claims that the government has gone too far.
Taking all of this account, the temptation is to err on the side of caution when it comes to e-cigarettes. It is a relatively new product on the market. Thousands use it. Anecdotal evidence says it can help you quit and other anecdotal evidence says it makes you worse. Some studies reckon that it’s far better for your long term health. Others say that it’s strongly related to binge drinking and is too easy for young people to buy. Undeniably, it is positioning itself as a cool accessory (“the new smoking” in effect). Uma Thurman puffs away at a cigarette in Pulp Fiction in 1994, and Rachel McAdams vapes with her electronic cigarette in True Detective in 2015. E-cigarettes are used by more and more every day. We don’t know it’s safe; not for sure yet. Steps should be taken to follow Wales’ lead. Tobacco has such a chronic effect on our health, we cannot run the risk that a new product takes its place. Even to have 1/20 of the effect of smoking on the world’s population is unacceptable. Big Tobacco is on board and most of the big guns have brands in the market, not subject to the same restrictive laws or taxes their cigarettes are. We should be worried.