WASHINGTON – E-cigarettes pose a public policy conundrum. They are a gateway drug – but it’s not, or hasn’t been, entirely clear in which direction most traffic through that gateway flows.
For some existing smokers, particularly those for whom other efforts to quit have failed, electronic cigarettes offer the advantage of a nicotine delivery device without risking the health consequences of smoking tobacco.
Meantime, for those not yet hooked, e-cigarettes present the risk of an alluring on-ramp to the real thing.
The question is whether the potential public health benefit of helping smokers quit outweighs the public health cost of enticing a new generation of addicts.
On the benefit side, the evidence is disappointingly inconclusive. The largest trial found that e-cigarettes were “modestly effective” in helping existing smokers quit, with verified quit rates of 7.3 percent versus 5.8 percent for the nicotine patch.
Indeed, even the e-cigarette industry is careful to emphasize reducing tobacco use rather than eliminating it. E-cigarettes are “probably the most effective tool right now in curbing the most preventable form of death we have in our society,” said Phil Daman, president of the Smoke-Free Alternatives Trade Association, an e-cigarette industry group. But, he added, “I am not saying this helps you stop smoking at all.”
On the cost side of the equation is the galloping growth of the market, particularly among youth, enticed by televised advertising that portrays e-cigarettes as an emblem of glamorous independence, with flavors such as cotton candy and banana split.
Whatever the precise balance, it has become increasingly clear that e-cigarettes require far tighter oversight and regulation than are now in place – especially as the Big Three tobacco companies have moved into the e-cigarette market.
“There is currently an enormous gap between what people hoped would be the public health potential of these products and the reality of what has gone on in the marketplace,” said Matthew Myers, director of the Campaign for Tobacco-Free Kids.
The numbers help explain Myers’ concern. E-cigarettes have been around for just over a decade, and they currently account for a tiny sliver of the market, just 1 percent.
But as total cigarette volume has declined 3 percent to 4 percent a year, according to Wells Fargo Securities analyst Bonnie Herzog, e-cigarettes have been growing at 20 percent annually. She predicts that e-cigarette consumption could pass conventional cigarettes within 10 years.
This could be good news, except for two unfortunate developments. First, many adults who use e-cigarettes continue to smoke regular cigarettes. Although tobacco consumption may drop for these dual-use smokers, the duration of tobacco use, not the amount of it, appears to be of greater concern when it comes to both heart disease and cancer.
More troubling, the Centers for Disease Control and Prevention reported recently that more than 260,000 youth who had never smoked a cigarette tried e-cigarettes – triple the number just two years earlier.
The youth numbers would be troubling even if none of the middle- or high-schoolers went on to tobacco products because of nicotine’s addictive properties and its particular impact on the still-developing adolescent brain.
Which makes the current regulatory void all the more alarming. In about 10 states and the District of Columbia, there are no restrictions on minors buying e-cigarettes. Rules against such purchases are toothless in many other states.
The Food and Drug Administration, importantly if belatedly, has proposed extending the federal ban on sales of tobacco products to minors to e-cigarettes.
But the FDA held off acting in two other areas: advertising and flavors. While cigarette advertising has been banned from television since 1971, in large part to diminish cigarettes’ allure to children, the FDA declined to restrict e-cigarette advertising.
As the American Heart Association observed last month: “Many of these advertisements have themes that promote rebelliousness and glamorize e-cigarette use. … Such marketing practices are likely to recruit a new generation of nicotine addicts.”
Similarly, while Congress banned flavored cigarettes (other than menthol) in 2009, again in an effort to reduce smoking among children and young adults, the FDA opted against regulating flavored e-cigarettes.
“The last thing that anybody in this industry wants is to indoctrinate youth or new vapers,” Daman said, referring to those who use e-cigarette vaporizers to inhale. “This is an adult consumer product for smokers.”
That’s a welcome sentiment. But one that will require vigilance to ensure that it reflects reality.
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